Effectiveness of Third Party Administrators in context to Indian Health Insurance

Author : Dr. Chhavi Anand
Objective To understand the effectiveness of Third Party Administrators in Health Insurance in context to India. Methodology The methodology involves extensive review of literature about the TPA scenario in India. It involves secondary research from research papers across India that have thrown light on the health insurance market in India and effectiveness of TPA in India. Introduction Third Party Administrators (TPAs) is expected to play an important role in the health insurance market in ensuring better services to policyholders. In addition, their presence is expected to address the cost and quality issues of the vast private healthcare providers in India. However, the insurance sector still faces challenge of effectively institutionalizing the services of the TPA. The findings of a survey in Ahmadabad revealed the experiences and challenges perceived by hospitals and policyholders in availing the services of TPA in Ahmadabad. The major findings were: low awareness among policyholders about the existence of TPA; policyholders mostly rely on their insurance agents; policyholders have very little knowledge about the empanelled hospitals for cashless hospitalization services; TPAs insist on standardization of fee structure of medical services/procedures across providers; healthcare providers experience substantial delays in settling of their claims by TPAs; However, there is an indication that hospital administrators foresee business potential in their association with TPAs in the long-run. There is a clear indication that the regulatory body needs to focus on developing mechanisms which would help TPAs to strengthen their human capital and ensure smooth delivery of TPA services.
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A Study of Provider‟s Perceptions in Delhi & the NCR by Rohit Kumar, K. Rangarajan , Nagarajan Ranganathan. This study examines the Indian health insurance market by empirically observing the provider‟s perceptions and its relationship with the insured, the insurer and the third party administrators (TPAs). The study tries to find out the awareness level among the insured population and their attitude towards treatment cost. It then examines the role of TPAs and the impact of cashless services on the cost of treatment by studying a few cost drivers. Apart from studying the provider‟s perceptions it also tries to look at some of the evidence of moral hazards and that of fraudulent activity. The findings suggest that the awareness level regarding policy terms and condition is low among the insured population and most of them do not care for the cost of treatment. The providers increase their rates quite frequently and prefer the middle income group for extending cashless benefits. The TPA model has not been successful in bringing down the claim cost but has helped in providing unbiased services including cashless benefits. The price structure of healthcare services are linked to the room rent category and most of the insured patients, who are more demanding, prefer staying in higher category rooms. The concept of cost-sharing by the insured will help tackle this issue to some degree. The Indian health insurance market is not immune from supply-side moral hazards and fraudulent activities and there is a need to craft different strategies to tackle them. There exists an opportunity for the insurance companies to build long-term relationships with the preferred healthcare providers by using technology and by understanding each other‟s roles in serving the common client. Third Party Administrators The introduction of Third Party Administrators (TPAs) is considered to play a vital role in health insurance industry. The escalating growth of private voluntary insurance companies in the healthcare market has led to rising cost of healthcare services. The Insurance Regulatory and Development Authority (IRDA) of India have opened the gateway to Third Party Administrators (TPAs) to ensure better services to policyholders. The need for TPAs arise to ensure quality care and better services to policyholders and to lessen some of the negative consequences of private health insurance. However, given the demand and supply side complexities of private health

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insurance and health care markets, insurance intermediaries face immense challenges. IRDA has defined the role of TPAs as one of managing claims and reimbursement; their role in controlling costs of health care and ensuring appropriate quality of care remains less defined. TPAs are expected to ensure better efficiency, standardization of charges and more penetration of health insurance in the country. Services offered by Third Party Administrators –  ID card: TPA provides ID cards to all their policy holders in order to validate their identity at the time of admission.  The TPA's undertakes "Pre-authorization" before a surgical procedure to ease claim processing  24 hours customer support services: The TPA provide assistance through their 24 hrs call centre that provides information regarding policyholder's data, provider network, claim status, benefits available with existing cardholder, etc All these details are furnished on request.  Cashless Hospitalization: Each policyholder is provided with a list of empanelled hospitals where in he/she can avail cashless hospitalization.  Claim Management: On behalf of the insurance companies TPA administers and settles claims for hospitals and policyholders. Policyholders have the privilege of expressing their grievances to the concerned insurance company or at the consumer's court if they are not satisfied with the services of a TPA. Regulation of Third Party Administrators   IRDA has approved services of TPA‟s as Insurance intermediaries(2001) IRDA has drawn up a code of conduct for the TPA‟s & put stringent conditions for

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licensing – e.g., working capital; appointment of man power etc.  More than one TPA may be engaged by an insurance company and, similarly, a TPA can serve more than one insurance company.    Refrain from trading on information and the records of its business; Assure cashless hospitalization facility with increased accessibility to healthcare. Any changes made from time to time in the agreement entered into by an insurer and a TPA shall be filed with the Authority;  A TPA shall not charge any separate fees from the policyholders which it serves under the terms of the agreement with the insurance company  TPA shall maintain proper records, documents, evidence and books of all transactions carried out by it on behalf of an insurance company in terms of its agreement.  TPA‟s are not allowed to market health insurance.

Market for TPAs in India The health insurance industry, which had underwritten premium of over `8,000 crore in 2009-10 (`6,625 crore in 2008-09) is expected to expand manifold because this sector is increasingly becoming an important line of business not only for standalone health insurers but also the existing players in the non-life industry. The health segment contributed 21.12 per cent of the total premium in 2009-10 (20.06 per cent in 2008-09) (IRDA Journal 2010). The four public sector insurance companies have hiked premium by 6 per cent since January 2003, apparently to factor in cost escalation as a result of the appointment of TPAs as mandated by IRDA. The TPAs are being paid 5.5 per cent of gross premium as commission. Based on a figure of over Rs 1,000 crore of premiums, this means that the total business for TPAs in India is about Rs 50 crore. Some business is, however, being conducted without TPAs. Based on the rate of growth of insurance premiums in just one year, it is possible that health insurance will grow much more

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in coming years, giving more business to the TPAs. Given the current business of about Rs 50 crore, it may seem that even these 47 TPAs are probably too many. The market is already divided among some that have cornered the major part of the business. However, while bigger TPAs are more effective, for pan-Indian operations, some of the smaller TPAs are also doing well in terms of quality of service, in their limited areas of operation. Success or lack of it depends on a fine balance of essentially three parameters: (a) share of total business, (b) availability of capital, and (c) geographic spread of operations. As in any market, the unsuccessful players are expected to exit the business. In the TPA market, the inefficient players, who are not able to satisfy their main customers, would in theory exit the market; however, as will be discussed below, this has not really happened in India. The reason ultimately is that the TPA market is not really like any other market: neither the entry nor the exit of TPAs from the market is really free. As mentioned above, the entry of TPAs was based on rationing of the total business and not a natural entry based on market considerations. Similarly, the exit of inefficient TPAs is also not due to market forces and, in fact, has not taken place at all. Experience with TPAs in India The initial performance of TPAs has not been up to the mark for several reasons, one of the main being the inability of some of them to deliver the goods. Perhaps the best way to introduce the TPAs was to run a pilot scheme and iron out teething problems, instead of changing the system almost overnight that involved a different mode of functioning for all the stakeholders. With so many TPAs entering the market with different capabilities and capital, it is not surprising that much confusion ensued. Those that had good links with hospitals earlier or who invested in tying up technologically with hospitals seem to be doing better than others. Similarly, TPAs that had not spread out too fast and too thinly across India seemed to have performed better than others. Unfortunately, discussions with insurance companies indicated that despite their non-performance, the TPAs were not blacklisted due to non-professional considerations.

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There are some other features of the new system that need to be taken into account to evaluate the functioning and usefulness of TPAs.

Individual vs. corporate business: Firstly, there is no doubt that the individual health insurance business is cross-subsidizing corporate business (often known as „accommodation businesses). The informal nexus among corporate houses, corporate hospitals, insurance companies and TPAs is ensuring that the claims ratio is high on corporate insurance, and low on individual insurance. Insurance companies agreed off the record that there often is pressure from corporate houses on insurance companies to get specific claims settled. This obviously means that ordinary policyholders are being subjected to stricter scrutiny.

Incentive for hospitals: For hospitals that are not also offering TPA or insurance services, there does not seem to be a great incentive to move over to the TPA system with delayed payment in contrast to the earlier system of on-the-spot payment. The discussions did indicate that some hospitals were not getting their payments on time and were reluctant to work with some of the current TPAs. However, as more and more health insurance policies are issued, even leading hospitals have to deal with TPAs. On the other side, some TPAs were of the opinion that the hospitals do not send the requisite information to them in time for them to be able to process the claims. The view is that hospitals have to be given substantial training before they can actually be an efficient part of this new system.

Hospital-backed TPAs: There is already evidence that a couple of hospital chains have got TPA license. This is certainly unethical and against the basic guidelines lay down by IRDA. This system will ensure that the TPA/hospital will work towards its own system, and there is always a possibility of playing favorites, that is, smooth claim settlement towards this hospital, and not to the other hospitals. This kind of system is, therefore, likely to bring in malpractices. At present, TPAs are not allowed to market health insurance policies due to a conflict of interest. However, it cannot be denied that a TPA that sells the policy will probably have an incentive to offer better services. Legally, it is difficult not to allow promoters to enter allied businesses as
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suitable equity structuring can always be done. But, due to the possibility of unethical practices, the IRDA/insurance companies need to ensure that a strict separation is maintained between these businesses. There are also instances of some TPAs working on behalf of corporate (IRDA Journal, January 2003), which is another area of collusion that is fraught with inefficient outcomes. In fact, a notice from the IRDA to TPAs and general insurers says that “it has been observed of late by the authority that the offices of various insurance companies and licensed third party administrators – health services are entering into agreements at the insistence of their clients for the sake of business considerations allowing TPAs to charge separate fees in addition to insurance premium. These TPAs although licensed by the authority, perforce have to enter into such agreements to ensure the survival of their operations in view of the reluctance by insurance companies to empanel and utilize them. It is hereby clarified that in the case of all such agreements which are out of the scope of IRDA (Third party Administrators – Health Services) Regulations, 2001 adequate precautions must be taken by informing the customer clearly of this fact.” While it is not clear exactly what this entails and how and what the customer should be informed about, the recognition of this phenomenon is an important development within IRDA. These points indicate that the system of TPAs, while theoretically sound and useful, is in practice fraught with problems.

Cost to consumer: Customers are paying for the extra service being provided by TPAs through a higher premium. If, in fact, the claims ratio is coming down and the insurance companies are being freed of their workload, then the savings in terms of both money and other administrative costs should be passed on to the consumers. This is currently not happening; insurance companies are not passing on the savings made in outsourcing administrative work being done by the TPAs. Of course, the claims ratio may be not coming down as significantly as it seems due to the presence of family floaters that are now being offered by insurance companies.

Marketing the universal health scheme: A new finance ministry initiative has been the universal health scheme, which was targeted at the poor. The premium of Re 1 per day was
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designed to bring in large sections of the less-well-to-do population under the insurance net. This has not happened for a variety of reasons, one of the most important being that poor families find it hard to pay Rs 365 per person or Rs 548 for a family per annum. Another reason for this scheme not doing well has been the lack of marketability of the product and the difficulty of reaching populations in the rural areas. The margin of profits for TPAs in this business is very low, and the TPAs do not seem to be interested in raising their share of this product. The insurance companies also do not seem to be very aggressive about selling this product to those below the poverty line, only 3,576 families of the 2,50,000 families covered were below the poverty line.4 The relevance of this in the context of the TPAs lies in scaling up of insurance for communities that are hard to reach or which are not apparently profitable to the companies. Given the low educational and economic status of communities that do not really understand insurance procedures, the role of TPAs takes on even greater significance. But the incentives are not conducive for them to want to service these policyholders.

Cost of healthcare: Cashless facility increases the capacity of policyholders to incur higher costs at the time of illness, and therefore has a tendency to inflate the demand for high-cost care. This could be limited to a certain extent with the presence of a system of co-payments. In any case, this tendency will be reinforced from the supply side, and there is a real fear that the presence of TPAs will facilitate the inherent cost-increasing nature of the current system, resulting in welfare loss for consumers. The mechanism is as follows: the presence of insurance will result in supplier-induced demand especially in diagnostics and super-specialty treatment. Hospitals would like to shape up for these types of services, which can only be done by accruing additional revenues from higher prices of healthcare. In principle, it is conceivable that: (a) consumers who do not have insurance pay higher costs, (b) consumers who do not have access to such five-star hospitals also pay the same high premiums, and (c) every policyholder may end up paying higher premiums sooner or later, that is, insurance companies may clamour for revision of premiums in the near future. Some of this could be limited if the insurance policies are more flexible in terms of the kind of facilities that can be availed: for instance, with sublimits, those who pay more can avail of costlier facilities. Of course, with more extensive
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coverage, and a certain degree of standardisation of services/costs, the increase in premiums can be contained somewhat. The other reason why premiums may go up would be the inability of TPAs to make enough profits, especially those TPAs that are spread out all over the country. Discussions with many TPAs revealed that there is dissatisfaction with the 5.5 per cent commission. There is a lot of variation in calculating break-even among the TPAs on account of their in-built costs. One player estimated the break-even in metros at Rs 10 crore of premium business and for nonmetros at Rs 4 crore, while another estimated the break-even premium at Rs 100 crore for the TPA. Some TPAs frankly admitted that they were making losses as of now, and hoped to turn things around in a few more years. The public sector general insurance companies should be bringing down their total management costs from about 30 per cent to about 20 per cent (as per the Insurance Act).

Findings: Few of the important findings are (1) Low awareness of policy holders about TPA (2) Policyholders mainly rely on insurance agents (3) Policyholders have very little knowledge about hospitals in network for cashless facility (4) Hospitals experience delays in settling of their claims by TPAs (5) Burden on hospital administrators as in time and effort after the introduction of TPAs (6) Standardization of fee structure imposed by TPAs on various healthcare providers (7) Lack of appropriate finance generating system – health insurance sector require much amount of working capital and bank guarantee to finance operations of TPA. But in the long run, hospitals administrators foresee business potential in their association with TPA. (8) The regulatory mechanism needs to be strengthened such that TPAs increase their human
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capital and there is smooth delivery of healthcare services in the coming years. References  Bhat Ramesh, Jain Nishant (2004a) Analysis of Public Expenditure on Health using State level data; Working Paper 2004-06-08, Indian Institute of Management Ahmedabad

Bhat Ramesh, Reuben B. Elan (2002); Management of Claims and Reimbursements; The case of Mediclaim Insurance Policy, Vilapa, 27, October – December, pg 15-28

Kalyani K.N. (2004a) Paying the bill! – The Great Indian Health Insurance Puzzle and its solution; IRDA Journal, October

Peter Lomas - Third Party Administration in the provision of In-Patient Health Insurance;; 2009

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Ramesh Bhat, Sumesh K Babu - Health Insurance and Third Party Administrators: Issues and Challenges ;; Working Paper No: 2003-05 Ramesh Bhat, Sunil Maheshwari, Somen Saha - Third Party Administrators and Health Insurance in India, Perception of providers and policyholders;; 2005 Vishwanathan S, Narayanan G.S. (2003) . Poor Hospital networks of TPAs dents Medicalim Cashless service plan ; Express Healthcare Management; 16-30 April 2003

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