Case Study On Tpa

A CASE STUDY ON THIRD PARTY ADMINISTRATION MODEL IN HEALTH INSURANCE Done by

V. ADITYA Register No. 02BCE007

Introduction TPA`s are licensed by Insurance Regulatory Development Authority (IRDA) to act as a Third Party Facilitator between Insured & Insurer and offers the following services: 1.Cashless medical service facilitation at Network Hospitals Up to limit authorized by Mediclaim / Hospitalization Insurance. 2.Claim processing and reimbursement, for Non-Network Hospitals. 3. Cost containment services for Insurance Companies and Insured with inadequate insurance. 4. Online assistance to Insured during hospitalization and filing of claim documents. 5. Enrollment of data / insured details and ID Card issuance. 6. MIS / Reports to Underwriter (online / offline) and Insured.

Relation ship between the TPA, insurer & insured can be exploited in the form of the following diagram:-

Fig 4.1 Relation ship diagram between the TPA, insurer & insured. The relation ship between the TPA ,the insurer and the insured can be studied from two perspectives. They are:-

1)TPA`s vs Insurer. 2) TPA,s v/s Insured

TPA`s vs. Insurer • TPA,s act as Complete back office set up for the Insurer. All underwritten policies are collected by TPA,s and enrolled and ID cards and Guide books issued to Insured. • Claims are settled by TPA,s under cash less scheme and also for reimburesement and amounts are reimbursed to TPA,s either on float or on Single window (Direct Banking ) platform. • TPA,s acts as custodian of Insurer fund and is responsible for timely settlement of claims, Service level delivery , Cost containment and maintenance of float accounting. • TPA provides data/MIS on enrollment , claims , CRCM, Call center. • TPA , responsible for grievance redressal. • Insurer audits the paid files and also validates service level deliveries. • TPA provides the complete IT platform with online access given to Insurer, analysis of data/claims , which acts are underwriting tools. • TPA acts as Gate Keeper and is responsible for fraud management.

TPA`s v/s Insured • Insured obtains TPA cards, cash less service ,claims settlement and support services, including, 24/7 information/ helpline .Queries on emails.• Timely Grievance redressal. All TPA,s have a grievance redressal mechanism well monitored by Insurer, IRDA and also accountable to Ombudsman, Consumer forums. • Corporate Help Desks, Awareness Campaign, CRCM cell , Mobile help lines. On line web access for E-cards and information on enrollment , claims , Network Hospitals and Infrastructure. Fig 4.2

TPA Model Diagram

Step-1 Enrollment 1. All underwritten data of members is collected by TPA for Enrollment. Insurers have now started giving electronic data and online enrollment is now possible. 2. Corporate clients intimate additions and deletions on a periodic basis to Insurer with a copy to TPA. Corporates have started uploading data directly into TPA system 3. All fields of the Insured are captured by TPA,s and ID card are generated and couriered to Insured directly along with guidebooks. 4. Insured/Insurer can track the enrollment/ID cards issuance and Dispatch details from TPA , Websites. 5.E -cards can be generated from TPA website against Policy No / Card No.

Cashless Service Process 1. Customer after taking the insurance policy. 2. The insurance company Sends the list of policy holders to the TPA. 3. Then the TPA stores the details of the insured in their database. 4. TPA issues Identity cards 5. And also provides 24 hour help line services. 6. when the customer goes for treatment,he informs the TPA and TPA sends him to one of their member hospital. 7. Then the TPA issues authorization letter for the customer.This is called cash less service. 8. The doctor treats the customer or policy holder till discharge. 9. Hospital sends the discharge voucher to the TPA Stating the cost. 10. TPA now submits the claim to the Insurance company. 11. And the Insurer Re-imburses the the amount.

The Following are the Types of Hospitalization Services:Planned Hospitalization -

Insured Approaches TPA Network Hospital with doctor prescription or meet consulting doctor.

Emergency Hospitalization - Insured Rushes to nearest Network/Non-Network Hospital - Inform TPA/Insurer about the situation.

Step-2 At the Time of Admission - TPA ID-Card is produced at Hospital reception - Hospital Fills-up pre-authorization form (Standardized documents) - Part I deals with name, card no., corporate name, etc. - Part III deals with declaration, previous policy/claim details, signatures. - Hospital will fill Part II – details like presenting complaints, clinical finding,line of treatment, past ailment history, date of admission, approx. duration of hospitalization, approx. costs (with break-up), signature of treating doctor.

Step-3 Authorization - TPA,s assess the pre-authorization request based on sum insured, clinical eligibility. - Query if any, will be faxed to hospital. Insured will be informed on phone. - Hospital will be given an authorization based on eligibility. Step-4 At the Time of Discharge - Insured to pay for all non-covered services like, registration fees, telephone bills, noncovered treatments, energy/soft drinks, chocolates, attendants rooms, etc.

- Insured to verify and sign hospital bill. To sign a claim form and leave all original documents at hospital. Xerox of relevant documents can be taken. - In case original investigation reports like, ECG, x-ray plates are required for future reference, insured to send request advice to TPA.

Claims Reimbursement - In case insured avails treatment at non-network hospital, he pays the treatment cost and claim a reimbursement from TPA. - 30 days pre and 60 days post hospitalization can also be claimed for both cashless and reimbursement hospitalization. -Insured to fill-up claim form and submit along with following original documents: - Doctors first prescription - Discharge summary - Hospital bills with all break-up - Investigation reports (x-ray, ECG, etc.) - All relevant medicine bills, pharmacy prescriptions, etc. -TPA will process the claim and e-mail/courier discharge voucher along with claim break-up to Insured, which will be signed and returned back to TPA and Cheque will be dispatched to insured.

Service Blueprint Process The steps involved in developing a blue print are as follows:  In identifying all the key activities involved in creating and delivering the service.  Specifying the linkages between the activities.  Any given activity should be refined to further steps to obtain a higher level of detail.  Key characteristic of blueprinting is it distinguishes between the front end and the back end activities.  Service blue prints can integrate all the departments in a company. 

Blue Printing gives managers to find the possible gaps in the process and helps them in preparing contingency plans.

Fig 4.3 Blue printing Flow Chart

P o l ic y L o o k U p E n q u i r y A b o u t t h e P o lic y P o li c y S e le c t io n Company Look up S e le c t in g t h e C o m p a n y E n r o ll m e n t D a t a b a s e L i s t in g V e r if ic a t io n E n r o l lm e n t Is s u e O f ID -c a rd s P r o v id in g A s s is t a n c e

Service Blue Print steps The service blue print for this model involves three entities namely: 1.Customer 2.Insurance Company 3.TPA We will analyze the model of TPA`s with respect to these three entities. Customer 1.Customer should first go through the policy list. 2.He enquiries about the policy which he is going to take. 3.Selects a policy. 4.Enquires about an insurance company. 5.Selects an Insurance Company. Insurance Company The activities that are involved in an insurance company are:1.Enrollment of data in their database. 2.Creating of the customer`s profile. TPA`s The steps involved in blue print with TPA `s are as follows:

1.Forwarding of details by the insurance company to TPA`s office. 2.Then the TPA will go through the details provided by the company. 3.Scrutiny of details. 4.If any details are missing TPA will ask the insurance company to provide them. 5.Now enrollment of data into their database will be done. 6.Issuing of a health card to the insured . 7.And assistance will be provided to the insured about the network hospitals and the various treatment facilities that will be provided by them, will be explained to him/her. 8.All other types of online assistance will be provided.

Gap Identification:Customers Regarding customers the following are the possible gaps identified and suggestions made: 1.Proper furnishing of data should be there about various policies 2.Interaction with customers should be swift and smooth. 3. People interacting with customers should be well trained and should posess adequate knowledge regarding the policies while interacting with customers on Phone or through direct contact. 4. Hospitality should be good for the customers when they come for the company in areas like:

-Ambience -Seating facilities -Counsellor-Customer ratio should be equal. - Other facilities. 4.Now manual form filling is available,online form filling should also be facilitated withpayment modes like Credit card and debit card. Insurance Companies:1.Back-End staff should be well trained. 2.Security of the Customer database should be Fool-Proof. 3. Possible back-up alternatives should be in place in times of crisis. TPA: :1.Proper listing of all the network hospitals. 2.Interaction with the customers on all aspects. 3.Due to the chances of frauds happening in cashless and reimbursement schemes appointment of an TPA representstive in all the network hospitals who will verify the bill and then forward it to the TPA`s office.

Conclusion:After analyzing the process model of Third party administration through service blue printing, possible gaps are identified and the suggestions are also made in accordance with them. As per the available data on the model the current gaps have been identified, but in practice these services may vary according to the company, so the gaps identified here will be useful only for a certain process model.For laying a successful base in analyzing the steps involved in the process model, if properly analyzed and implemented the process model could effectively address many problems that are being faced by TPA`s with insurers and hospitals, and can definitely provide better services to the policy holders.