How Third-Party Administrator (TPA) helps in Easy Health Insurance Claims

Health Insurance Claims

You must have a health insurance policy for all your family members, whether it is children or your elderly parents. You may find yourself or any of your loved ones in an emergency medical situation. Without a financial cover, arranging the hospital bills or treatment costs would be extremely hard. At such a time, you must focus solely on the treatment. But, if you have a health cover, whether individual or a family floater, you may claim the medical expenses. The Third-Party Administrator (TPA) plays an important role in the claim settlement process. Let’s look at the TPA in detail and how it functions.

What Is A TPA?

A TPA is an organisation that performs the administrative works such as record keeping, claims processing, etc., on behalf of a company or an employer, who provides health coverage to its employees. The Insurance Regulatory And Development Authority Of India (IRDAI) set up this special agency in 2001 to help insurance companies settle claims among other tasks.

Large corporates with many employees have tie-ups with TPAs, who manage the different processes associated with medical insurance.

Role Of TPAs in Health Insurance Claims Process

  • Managing Diverse Activities

Insurers manage several complex processes and issues to provide the best service to its policyholders. So, they prefer a professional team to take care of the diverse activities associated with the health insurance industry.

The IRDAI issues licences to the TPAs, which are outsourced firms. They provide services, such as processing claims and cashless facilities for the insurer, based on these licences.

  • Help Policyholders During Claims

TPAs help you have stress-free claim settlement. They co-ordinate with the insurer, the hospital or medical service provider, and yourself. Whether it is extracting your details, obtaining claim approval from the insurer, or settling the hospital bills, the TPA manages it all. They act as an intermediary between you and the insurance company to ensure that there’s no hassle settling your cashless and reimbursement claims.

  • Shares your burden of responsibilities

An emergency medical condition related to your loved ones accompanies with it shock or trauma. You stress over quick patient admission, first-aid from the doctors, and the advance payments to the hospital to start the treatment. In such a situation, the TPA steps in to ease your burden, particularly in the case of cashless claims. As soon as you produce the cashless cards at the hospital counter, the TPA manages everything till the patient is comfortably discharged.

  • Single point of contact

The TPA is directly in touch with the insurance company, brokers, hospitals, policyholders, etc. They are the point of contact for processing the claims and other functions as well as the individuals associated with health insurance.

  • Ensure authenticity of claims

You can rely on the TPA if there is any medical emergency. They will provide information regarding your nearest network hospital, negotiate for treatment charges with the hospitals, pay your bills, etc. As per IRDAI regulations, TPAs have their team of doctors, legal experts, insurance consultants. These professionals study the case in depth and ensure that there are no fake claims or discrepancy in documents.

  • Knowledge about health insurance

TPAs have immense knowledge about health care services and are well-equipped to carry out proper investigation related to medical cases, provide quality services, and adhere to a timeline.

  • Build hospital networks

The TPAs are responsible for building hospital networks and engage in tie-ups with medical service providers for cashless claims and negotiate for treatment charges.

How TPAs Manage Your Claims?

  • If you require medical treatment, you must get in touch with the TPA of your insurer.
  • The TPA will let you know about the nearest network hospital and help you with the claim process.
  • Before discharge, you must send all medical bills to the TPA for payment.
  • The TPA will scrutinize the bills and verify them against your coverage.
  • Once they approve all the documents and bills, the insurer will directly settle the expenses with the hospital or reimburse them.

The TPA is associated with activities such as:

  • Claim settlement
  • Processing cashless and reimbursement claims
  • Providing a list of network hospitals to the policyholder
  • Processing online pre-authorisation with a hospital
  • Tracking claims
  • Arranging for ambulance services
  • Providing 24-hour toll-free helplines
  • Other health facilities

So, TPAs are the leading support behind any insurance company since they perform the major tasks on their behalf.