The challenges perceived by hospitals and policyholders in availing services of TPA are

y y y

Policyholders mostly rely on their insurance agents Low awareness among policyholders about the existence of TPA. Policyholders have very little knowledge about the empanelled hospitals for cashless hospitalization services. In settling of their claims by the TPAs, the health- care providers experience delays as the TPAs insist on standardization of medical services/ procedures across providers. Hospital administrators perceive significant burden in terms of effort and expenditure after introduction of TPA. Hospital administrators foresee business potential in their association with TPA in the long run though as of now there is no substantial increase in patient turnover after empanelling with TPAs.

Future role In the fast developing health insurance sector the TPAs have crucial roles to play in the future. Some of them are y

Medical

examination

services

for

life

insurance

policies

and

overseas mediclaim policies

y y y y y y y

Record verification under adjustment policies Documentation and policy issuing. Co-insurance recovery services for both premiums and claims Follow up of recoveries from reinsurance companies Servicing of motor policies Arbitration services Inspection and assessment of risk prior to issuing the policy

Developing viable mechanisms would help TPAs to strengthen their human capital and ensure smooth delivery of their services in an emerging health insurance market.

The specialized functions of the TPA include:

y

The TPA keeps and maintains all the records of medical insurance policies of an insurer. The TPA issues identity cards to all the policyholders. The policyholders will have to show the identity cards to the hospital authorities before availing any services from the hospital. In case of a claim, policyholders will have to inform the TPA on a 24 hr toll- free line provided by them After informing the TPA, the policyholder will be directed to a hospital where the TPA has a tied up arrangement. However, policyholders have the option to be admitted at another hospital of their choice in which case, payment will be on reimbursement basis. TPA pays for the treatment; they issue an authorization letter to the hospital for the admission of the policyholder in the hospital. At the point of discharge, all the bills will be sent to the TPA while they are tracking the case of the insured at the hospital. TPA makes the payment to the hospital. TPA sends all the documents necessary for consideration of claims, along with the bills to the insurance company. The insurance company then reimburses the TPA

y y