Types of Health Insurance Policies that Require Third-Party Administrator Services

If you have ever bought health insurance policies or filed a claim, then you must have heard the term Third-Party Administrator or TPA. Some of you might be aware of the role TPA plays, but for those who are policyholders and do not know the term, TPA is an agency that holds authority and license from Insurance Regulatory Development Authority (IRDA) to process claims. It works as a mediator between a policyholder and an insurer.

The three major stakeholders of the TPA are health insurance companies, healthcare providers, and policyholders. This blog will discuss the role TPA plays in the claim settlement process and the types of health plans which require TPA.

Role of TPA in Health Insurance Policies

Third Party Administrator services are chosen by the medical insurance company, which makes the process of claim settlement easy and smooth. The major role of TPA can be understood through the following points:

• Works as an intermediary in the process of claim settlement.
• Maintains crucial records related to policyholders during hospitalisation.
• Offers backend support and coordinates between the hospital and insurance company.
• Provides customer support 24*7.
• Sometimes, provides additional services like extra beds, ambulances, medical supplies, etc.

How does TPA work?

TPA has a significant role in processing both types of claims, i.e., cashless treatment and reimbursement treatment. Let's dive deep and understand more about the work.

Cashless Treatment

Once you decide to choose the cashless treatment, you have to contact the TPA of the medical insurance company. They help in choosing the right network hospital and guide you on the hospital desk and submission of the required documents. After the approval, the TPA settles the medical treatment expenses with the hospital.

Reimbursement Treatment

You might be wondering, if you go for a non-network hospital, then how would your health plan be utilised? You do not need to worry in such cases, as you have an option of getting reimbursement for the medical bills you paid during the treatment. In this case, the TPA guides you with the list of important documents which are required for successful reimbursement. After the claim gets approved, the medical insurance company transfers the associated amount to your bank account within a few days.

Types of Health Insurance Policies that Require Third-Party Administrator Services

Every insurer appoints Third Party Administrator to ease the process of claim settlement. There is no insurance company that works without a TPA. Every health insurance requires TPA, and you, as an insured, must inform the insurer within 24 hours of emergency hospitalisation to avail of cashless treatment. In case of planned hospitalisation, you need to inform the insurer at least two days before the beginning of treatment.

Benefits of TPA for Policyholders

TPA was introduced to reduce the burden on health insurers. It maintains communication between the stakeholders and provides the following benefits to policyholders through its services:

• Cashless Claim: During hospitalisation at the network hospital, TPA collects the required documents to start the process of cashless claims. It provides 24*7 support to the policyholder.
• Assistance with Hospitalisation: TPA issues health cards on behalf of the insurer. This allows patients’ family members to avail of the medical facilities. TPA also provides back-end services to assist the stakeholders.
   
• Reduces Claim Processing Time: The existence of TPA has improved the quality of insurance services. It reduces the processing time of documentation for claims and payments.
   
• Improves Standard Operating Procedures (SOP): As a large number of hospitals and insurance agencies are involved, SOPs help to standardise the process of claim settlement.

Benefits of TPA to Insurance Companies

TPA, with its services, has benefited both the insurer and the insured in different ways. Other than the advantage of an intermediary, here are some key benefits which an insurer can get:

• Serves the main objective of the business, i.e., claim settlement.
• Coordinates the process right from the beginning of treatment to discharge.
• Manages and investigates claim requests.
• Maintains the image of the company with superior quality of service.

To Sum Up

TPAs come into the picture as soon as you are required to file a claim. This has not only helped companies smoothen and fasten the claim settlement process but has also impacted the quality of service a consumer expects. By playing the authorised role of the intermediary, TPAs have reduced the chances of corruption.

If you are looking to buy best mediclaim policy for family, then you must choose an insurer that has a high ratio of claim settlement along with a smooth process of documentation. One such insurance company is Niva Bupa, which has been serving policyholders with high satisfaction. This wise decision will help you in the future at the time when you require it the most.