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Case Study on TPA

Case Study on TPA

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Published by Jackie Lester

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Published by: Jackie Lester on Nov 24, 2009
Copyright:Attribution Non-commercial

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11/03/2012

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A CASE STUDY ON THIRD PARTY ADMINISTRATIONMODEL IN HEALTH INSURANCE
Done by
V. ADITYA
Register No. 02BCE007
Introduction
TPA`s are licensed by Insurance Regulatory Development Authority (IRDA) to act as aThird Party Facilitator between Insured & Insurer and offers the following services:1.Cashless medical service facilitation at Network HospitalsUp to limit authorized by Mediclaim / Hospitalization Insurance.2.Claim processing and reimbursement, for Non-Network Hospitals.3. Cost containment services for Insurance Companies andInsured with inadequate insurance.4. Online assistance to Insured during hospitalization and filingof 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 theform 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 arecollected 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 andamounts 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 leveldeliveries.• TPA provides the complete IT platform with online access given toInsurer, analysis of data/claims , which acts are underwriting tools.• TPA acts as Gate Keeper and is responsible for fraud management.

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