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The information given in this course material is merely for reference. Certain third party terminologies or matter are used only for contextual identification and explanation, without an intention to infringe.
The information given in this course material is merely for reference. Certain third party terminologies or matter are used only for contextual identification and explanation, without an intention to infringe.
Hak Cipta:
Attribution Non-Commercial (BY-NC)
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Unduh sebagai PDF, TXT atau baca online dari Scribd
The information given in this course material is merely for reference. Certain third party terminologies or matter are used only for contextual identification and explanation, without an intention to infringe.
Hak Cipta:
Attribution Non-Commercial (BY-NC)
Format Tersedia
Unduh sebagai PDF, TXT atau baca online dari Scribd
This document should not be carried outside the physical and virtual boundaries of TCS and its client work locations. Sharing of this document with any person other than a TCSer will tantamount to violation of the confidentiality agreement signed when joining TCS.
Notice The information given in this course material is merely for reference. Certain third party terminologies or matter that may be appearing in the course are used only for contextual identification and explanation, without an intention to infringe. Certificate in Health Insurance TCS Business Domain Academy
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Contents
Chapter - 7 Health Insurance Administration .................................................................... 4 Introduction ...................................................................................................................... 4 7.1 Administration of a Health Insurance ..................................................................... 5 7.2 Governance functions ............................................................................................ 5 7.3 Management Functions ......................................................................................... 5 7.4 Administrative Functions ....................................................................................... 7 7.4.1 Collecting Premium ........................................................................................... 8 7.4.2 Empanelling Providers ....................................................................................... 8 7.4.3 Authorizing admissions ......................................................................................9 7.4.4 Processing of claims ...........................................................................................9 7.4.5 Managing the Funds ........................................................................................ 10 7.4.6 Personnel Management ................................................................................... 11 7.5 Monitoring ........................................................................................................... 12 7.6 Third Party Administrators (TPAs) ....................................................................... 15 7.6.1 Structure of TPA: ............................................................................................. 15 7.6.2 Roles and Responsibilities of a TPA .................................................................. 16 7.6.3 Types of Health Insurance Claims .................................................................... 18 7.6.4 Benefits of TPAs .............................................................................................. 19 7.6.5 Revenue generation for TPAs .......................................................................... 20 7.6.6 Challenges and Scope for TPAs .................................................................... 21 Summary ........................................................................................................................ 22 References ...................................................................................................................... 25
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Chapter - 7 Health Insurance Administration
Introduction Managing health insurance scheme is a cumbersome job. It involves various administrative functions to perform for effective management of the policy. Because of the diversity and skill set required to perform these functions, various professionals like actuaries, finance managers, legal managers are hired to do such job. This chapter covers the administrative aspects of health insurance like activities involved in running a healthcare scheme and several performance metrics that are used to monitor the scheme.
Learning Objectives On completion of this chapter, you will understand the: Administrative system and functions of health insurance Various performance measurement metrics of insurance schemes Different skilled professionals required for functioning of a health insurance scheme Roles and functions of Third Party Administrators (TPAs)
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7.1 Administration of a Health Insurance
Administering an insurance scheme is a complex task. To begin with, the organiser of the scheme needs to take responsibility for the scheme. This is the entity that will finally be accountable for the success or failure of the scheme. Most successful health insurance schemes have a clear administration.
Generally this function is performed by a regulator body. And when it comes to the internal aspects of the company, it is the organizer who performs this role. Proper governance is essential for functioning of any system. When it comes to the health insurance sector, primary objective of governance would be to engage all the stakeholders in order to attain a common goal, which is to provide an affordable healthcare to the entire population. It will serve the interests of the providers, the community, the insuring companies and the governments.
It is the organiser who will be deciding which community should be targeted, the overall design of the scheme and the extent of subsidies that will be made available. They also monitor the macro indicators like financial status of the scheme, the utilization rates and any major grievances from the community or providers. 7.3 Management Functions
In the business of insurance there are certain managerial functions that either an organizer or the insurer would have to perform or might delegate it to another agency. These management functions can be broadly categorized as:
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Creating awareness about the health insurance This is an important but often neglected function. Managers usually assume that people are aware about health insurance and its complexities. But they have to set aside such pre-conceived notions and will have to make use of every opportunity available to educate and enhance the knowledge of customers about health insurance. Training the staff/community representatives Not only do staff need to be trained on the policy/ scheme, they should also be given detailed inputs about health insurance. This is necessary so that they will be able to answer the questions posed to them by the community. Negotiating with insurance companies Most insurance companies look at the scheme from their perspective, i.e. to make profits. So it is essential that the communitys needs as well as the insurers requirements are also met. Hence it is important to keep such things in consideration while preparing the policy document. Negotiating with providers Providers (hospitals) usually are interested in increasing their occupancy and profits. Quality of care, access to healthcare and financial protection is secondary to them usually. Hence, it is imperative that the insurer negotiates on behalf of the insured community to ensure that people get the benefits that they have contributed towards. Fixing the benefit package and the premium This is an important part of the management function and should be negotiated between the community and the insurer. A balance has to be maintained between the community needs, technical requirements and affordability. Marketing the product Marketing the product is different from creating awareness on health insurance. It is closely linked, but here the emphasis is on convincing the community to subscribe to the insurance policy. Managing risks Any scheme needs to be self-sufficient. For this, moral hazard and adverse selection need to be minimized. The organizer needs to introduce these measures so that the scheme is protected against bankruptcy. Controlling costs Mechanisms to control costs need to be introduced into the policy right from the beginning. There exist various provider payment mechanisms that will have to be chosen among in order to achieve that objective. Controlling fraud Fraud is one of the banes of health insurance, and no country is spared from this. Fraud can arise from any of the participants in the framework of Certificate in Health Insurance TCS Business Domain Academy
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the health insurance, might be from hospitals and doctors through unnecessary treatments, from the insured community by ways of falsified claims or from the insurer by way of accounting malpractices. Measures to prevent fraud, especially by doctors and hospitals are required. For this the organizer needs to employ medical officers who will be able to see through the machinations of providers. Redressing grievances This is yet another important function that is often neglected. People need to air their grievances associated with the system. It has got two advantages one, it makes the community feel in control of the scheme. And two, it gives the insurer insight into the performance of their scheme. Grievances can be useful in fine-tuning the schemes over time. Monitoring the policy Mere creation, launch and administration would not serve the purpose of performance enhancement, there should be a constant monitor on the system (this will be discussed in detail in the later part of the chapter). 7.4 Administrative Functions
Administration is an important component in the smooth operation of the insurance policy. Either the insurer or the organizer takes care of these functions. Once the insurance policy has been designed, it is the responsibility of a team of efficient administrators to implement the insurance scheme without any hurdles. Any insurance policy will typically involve a large number of people. Transactions take place at different places at different times. Documents need to flow smoothly between various stakeholders and financial details of each subscriber and of the entire policy need to be closely monitored. Hence, it is essential that a good administrative system is established and the various tasks involved at every stage are clearly articulated to the team members. Administration can take place with a team within the insurance company, or within the organizer. It can also be outsourced to Third Party Administrators (TPAs). These are legal bodies entitled to perform such functions for an insurance company.
Broadly, the major activities involved in the administration of an insurance scheme can be listed as follows: Collecting premium Empanelling providers Authorisation of admissions Processing claims and reimbursements Certificate in Health Insurance TCS Business Domain Academy
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Managing funds Personnel Management MIS Reports for Monitoring 7.4.1 Collecting Premium Premiums are collected from individuals or from groups. Either way, there will be an Enrolment Form, which the potential insured person is required to fill. The insurer collects various details of the individual (and his/her family) through the process of filling the enrolment form. The profile of the members in terms of their age, sex, previous medical history, pre-existing illnesses, address, etc. are obtained through the enrolment form. However, in group memberships, there may be just one enrolment form for the entire group. Here just a list of the members has to be attached to this single form.
The enrolment form and the premium are paid to the insurer who in turn insures the individual/group. In the case of renewals, there is no need for a new enrolment form. The insurer issues a policy document that gives the details of the insurance scheme, the benefits, the validity period, the exclusions and any disclaimers.
The organiser should also maintain financial records of the amounts collected, and the number of individuals/ families/groups insured as well as their details. 7.4.2 Empanelling Providers The insurer negotiates with hospitals in the vicinity of the target population for treating patients under the insurance scheme. The insurers team ascertains the services and facilities available with the hospital in terms of qualified personnel (doctors, nurses, pharmacist, laboratory personnel, etc.), diagnostic tools/equipments and infrastructures like labour room, operation theatre, and separate wards for sick patients/infectious diseases, etc.
The insurance team would then negotiate the costs that the hospital will charge for the patients for various procedures and the treatment protocol for various diseases. Once the treatment procedures and the charges for the majority of the diseases are mutually agreed and standardized, then that hospital can be empanelled as a Provider under the insurance scheme. The list of empanelled providers should accompany the policy document, so that the patient knows where to go when ill. Certificate in Health Insurance TCS Business Domain Academy
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A small team in the hospital will be trained on the terms and administrative procedures involved in the insurance policy. 7.4.3 Authorizing admissions When the insured member becomes ill, and seeks medical treatment from an empanelled provider. In the case of a reimbursement mechanism, there is no need for pre-authorisation. The patient gets admitted, pays the bill and then gets reimbursed by the insurer. On the other hand, in the case of a cashless mechanism, if the provider feels that the insured patient requires admission, then the member is supposed to get a pre-authorization from the insurer (or a TPA). 7.4.4 Processing of claims There are two common routes for receiving claims. One is from the provider (in a cashless system) and the other is from the individual insured patient. In either case, the insurer/TPA will review the following: Confirm the identity of patient Confirm whether the patient had a pre-authorization Confirm whether the patient was admitted during that period Assess the diagnosis and the appropriateness of the treatment Assess the cost of treatment
Figure 1 Process of claims and reimbursements
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Claims are of two types based on their nature (will be dealt in detail at the end of this chapter): Cashless Hospitalization: Here the insurer or the TPA takes care of settling the bills with the hospital, it is a hassle free process for the policyholder as he/she is not required to pay anything out-of-pocket and later wait for the reimbursement. Reimbursement Claim: In this case, initially the policyholder would settle all the bills with the hospital and latter as per the procedures and policies of the insurance company submits those bills, which upon scrutiny will be reimbursed by the TPA or the insurer.
The documents required will vary from scheme to scheme, but usually the minimum required are: Copy of policy document The discharge summary, hospital bill, prescriptions, laboratory reports, medical and laboratory bills all original documents If all the documents are acceptable, then the insurer will reimburse the amount to the insured/provider/organizer. 7.4.5 Managing the Funds The insurer ideally should have the financial systems to manage the funds received as premium from the members and keep track of the claims and reimbursements made to individual members. To put it simply, the insurer receives funds from all the members initially and then reimburses their expenses from this pool over a period of time as and Claims Type Cashless Hospitalization (Emergency / Planned) Reimbursement Claim Certificate in Health Insurance TCS Business Domain Academy
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when claims are received. Hence, the insurer needs to have good systems for fund management.
The following tasks are involved in the management of funds by the insurer:
Budgeting administrative expenses: The insurer will be incurring administrative expenses in terms of salaries of personnel, overhead costs like telephone and other office expenses, etc. It is important that a budget is prepared for these expenses and they are monitored to see whether they are within the estimates.
Estimation of Cash flow: The insurers main task will be to estimate the cash flow and estimate the possible outflow of funds. If the members/providers/intermediaries are expected to send the claims on a monthly basis, then the insurer should also try to make the cash flow projections on a monthly basis, taking into account the administrative expenses.
Investing Funds: Depending on the cash flow projections, the unutilised funds available with the insurer should be invested in banks/other options. The interest earned from such investments will be a significant income for the insurer and should be aimed to meet a significant portion of the administrative expenses of the insurer. 7.4.6 Personnel Management The services of the following personnel are required by the administrative team of the insurer: Medical Professionals: The terms of the insurance policy may involve details of diseases that are covered/ exempted and hence inputs from a doctor are essential while processing the claims. Moreover, the treatment given to the members and the costs incurred need to be examined by a qualified medical professional. The insurer may do well to have broad parameters for monitoring the claims in terms of the prevailing diseases, incidence of a particular kind of illnesses, average costs for different categories of procedures, etc.
Actuarial/insurance professional: When the insurance policy is designed, the company is expected to do an analysis of the historical data with respect to prevalence of diseases among the insured population, historical data of charges Certificate in Health Insurance TCS Business Domain Academy
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prevailing in the various hospitals/providers, the expected rate of claims, etc. As the policy gets underway and the company starts receiving the claims, an analysis of the actual data compared to the earlier estimates shall be done by the actuarial/insurance professional on a monthly basis to ensure that there is no malpractice or flaw in the programme. This close monitoring will help design the policy for subsequent years.
Finance/Programme Manager: The profitability of the insurance programme depends on the fund management efficiency of the insurer as well. The company will have invested the unutilised funds in short-term/medium-term deposits and the interest income is crucial for the programme. So, the finance/ programme manager should keep track of funds on a regular basis and make suitable investment decisions. The cash flow projections made at the beginning of the policy period shall be revisited at least on a monthly basis. The administrative expenses also will have a bearing on the cash flow of the programme and hence the finance manager will monitor these expenses as well.
Legal Professional: The insurance policy issued at the beginning of the policy period is a legal document and hence needs to be drafted according to the existing laws that cover insurance. The inputs of a legal professional, particularly well-versed with medico-legal cases, will be useful. Similarly, if there are any disputes regarding claims and reimbursements between the insurer and the members/providers, one party may resort to court to settle the disputes. Hence, it is important to keep a legal professional also as part of the team and get all the documents approved by her/him. 7.5 Monitoring
The performance of an insurance scheme will be measured on various metrics. The commonly used indicators/ metrics are:-
Coverage rate - Percentage of people insured with respect to the target population. Even in some of the best schemes, the coverage rate might reach a maximum of 40 - 50%. Only in mandatory schemes or in social healthcare does the coverage reach 75100%. Certificate in Health Insurance TCS Business Domain Academy
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Renewal rate Proportion of people who were insured in the consecutive year. This is a good proxy indicator of the quality of the insurance scheme. Good schemes have a renewal rate of about 50 per cent. This indicates that people are happy with the scheme and are willing to rejoin it.
Utilization rate - Percentage of people who had accessed healthcare. This depends on the benefit package. For general hospitalization the rates range from 24%. In rare cases, it can be as high as 710%.
Claims Ratio - The ratio of the amount of reimbursements made to the total premium amount received by the provider. This gives a financial overview of the scheme, whether it is viable or needs to be modified.
Status of the insurance fund A kind of income and expenditure statement, indicating the cumulative premium amount collected under the scheme, reimbursements made, the administrative expenses incurred and the interest income earned.
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Liquidity Status - The liquid cash available in the insurance fund at the end of every month (that has not been invested in any instruments/banks). A ratio of this amount to the average claim amount per month will give us the number of months the fund can service the claims.
Solvency ratio The assets divided by the liabilities of the scheme. It indicates the financial strength of the insurance policy and its ability to pay its obligations now and in the future.
Report of the rejected claims Reasons for rejection and the claim frequency. An analysis of this report will help the insurer plan an awareness campaign either among the Members or among the hospitals about the provisions of the insurance scheme. Promptness of claims settlement This gives an idea about the efficiency of the insurer. Many schemes have suffered from delays in reimbursing the patients/ providers leading to loss of the scheme credibility. Certificate in Health Insurance TCS Business Domain Academy
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7.6 Third Party Administrators (TPAs)
Third party administrators (TPAs) are neither healthcare providers nor insurance companies; they act as intermediaries by bringing all components of healthcare such as physicians, hospitals, clinics, long-term facilities, and pharmacies together.
A Third Party Administrator is an organization that handles the administrative aspects of a health insurance company that include processing insurance claims or managing employee benefit plans of a separate entity.
A TPA can be an entity of an insurance company or an independently operating organization that handles the outsourced administrative functions of multiple insurance companies. 7.6.1 Structure of TPA
Figure 2 TPAs in Health Insurance
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Their services include: Cashless service at hospitals Call centre support to policyholders Medical cost management Management of claims and reimbursements
List of professionals that TPAs hire for administering such services include: Medical doctors Hospital Managers Insurance Consultants Legal Experts Information Technology professionals Management Consultants
For an effective administration TPAs require skills to: Develop network Managing finance Delivering appropriate healthcare service to its clients
7.6.2 Roles and Responsibilities of a TPA The basic responsibility of a TPA is to bridge the gap between the insured and the insurer by providing quality service at an economical cost. In order to provide such services, TPA has to follow certain best practises like:- They play a major role in assimilating data for actuarial calculations, because they are in possession of morbidity data that are linked with individual characteristics such as age, sex etc., TPAs should procure all the relevant information of the policyholders from the insurers and must issue identity cards to the policyholders which can be furnished to the hospital authorities prior to availing any hospitalization services. TPAs should disclose to the clients the healthcare services that it is authorized to render based on the contract and bring to the notice of the insurer any adverse report, inconsistencies or material facts that are relevant to the insurance companys business. Certificate in Health Insurance TCS Business Domain Academy
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A TPA must maintain proper records, documents, evidence and book of all transactions carried out by it on behalf of an insurance company as per the terms of agreement. And such records must be preserved at least for certain period of time. The records that are to be maintained in conformity with the accepted accounting and professional standards should be made available to the insurance company and the regulatory bodies as and when required and TPA cannot deny access to these authorities on any ground. TPAs should maintain strict confidentiality about the information and records of its business and about the records of its clients unless required to be produced to an authority authorized to per use the records or called for by a court of law. At the time of claim settlement, the TPA should collect all the required documents pertaining to the claim arising out of the insurance contract concluded by the insurance company with the policy holder. The TPA should provide all the required assistance specified under the agreement and advise to policy holders or claimants or beneficiaries in complying with the requirements for settlement of claims with the insurance company. Under no circumstances should a TPA overtly or covertly influence the policyholder of an insurance company to switch loyalty to some other insurer. The TPA should not resort to any unethical practise in its dealings with the clients, like asking a client to suppress information or provide wrong information or demand a cutback from the claims proceeds. The TPA should not charge any fee from the policyholders contravening the terms of the contract. In case of non-renewal of the contract, revocation or cancellation of the license, the TPA should hand over all the records, book of accounts, documents and collected data etc.., to the insurance company immediately. A TPA is required to prepare an annual report duly authenticated by the directors and the CEO/ CFO of the company and make it available to the insurance company as well as the regulatory.
In this context a Network Hospital means a network of hospitals, nursing homes and healthcare providers approved and empanelled by the company and considered as the preferred medical centres or establishments.
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And Cashless Hospitalization means that as a healthcare policyholder, one need not have to furnish the hospital bills and then get the reimbursement later. On the contrary, the policyholder will be able to avail of medical services at designated hospitals, and the concerned TPA will settle the bills.
7.6.3 Types of Health Insurance Claims With TPAs being introduced into healthcare, the delivery mechanism of insurance has taken several shapes. Now an insurance policyholder can opt any of these three options: Get treated in any one of the hospitals by availing cashless facility Get treated in a network hospital without using the cashless facility Get treated in a non-network hospital.
Because of these available options, claims can be categorized into three types: Cashless Hospitalization Under the cashless hospitalization scheme, the insured is spared the hassle of filling the claim papers, attaching the supporting documents, submitting the claim and waiting for the settlement of the claim.
Process of availing cashless hospitalization: Depending on the need, urgency and status of empanelment of the hospital there are certain steps that are involved before availing this facility, they are: Once the health insurance contract is concluded, the insurance company communicates particulars regarding the insured to the TPA concerned. On receipt of this information, the TPA will write to the policyholder and advise him/her on the procedure for obtaining the identification card that will enable the policyholder to avail of the cashless facility in any of the network hospitals. Once this is done, the policyholder may face two types of situations, viz., planned hospitalization or an unforeseen medical emergency
Planned Hospitalization In this case, the policyholder needs to undergo following phases: He/she is required to take pre-admission authorization from the authority designated for the purpose by the insurance company and then submit in advance as specified. Certificate in Health Insurance TCS Business Domain Academy
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The designated authority of the company or the TPA upon receiving this request would examine the request as to whether it would meet the terms and conditions of the policy, cover limit, exclusion clause etc.., If all the criteria are met, the designated authority would authorize the concerned hospital to offer the cashless facility.
In certain cases the authorization maybe rejected for following reasons: There was a suppression of pre-existing conditions Recommending physician note contains information about the ailment Based on the details given by the recommending physician, the ailment falls under the category of excluded diseases
Unforeseen Emergency In this case, it is practically infeasible to get the pre-authorization done. Hence there exists a different process under this scenario.
On admission, the policyholder or his/her authorized representative should notify the TPA about the whereabouts of the hospital, provisional diagnosis, duration of stay in the hospital and approximate expenses. This notice has to be served within the stipulated timeframe as per policys terms and conditions. Thereafter, the TPA will examine the bill and settle it with the hospital according to the eligibility conditions.
After settling the accounts of the hospital, the TPA will send all the relevant claim papers to the insurance company to get the reimbursement and the TPA commission as per the agreement. 7.6.4 Benefits of TPAs TPAs bring down the claims ratio, by reducing false claims as well as standardizing treatment costs. Some of the common benefits by introducing TPAs are: Faster and focused claims management Lower overhead cost and reduced cost of claims management Immediate access to highly trained claims administrators Improved control over claims outcomes Provision of cashless services at much ease Certificate in Health Insurance TCS Business Domain Academy
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Safeguarding of customer relationships Protection of brand reputation Control of possible frauds by the private healthcare providers 7.6.5 Revenue generation for TPAs The primary revenue for TPAs is the fee charged for managing the claims of the insurance companies. Such fee is based on the volume and scope of services provided by them and it usually is a fixed percentage of the premium collected from the enrollees. Apart from this,
TPAs provide many other services to the insurance companies for which the organization directly pays the fee. Such services include: Benefit management: While designing group insurance policies and new policies by the insurance companies, TPAs come handy.
Medical management: It involves a generic follow up of the case and monitor how treatment is rendered and ensure it is genuine.
Provider network management: It is one of the key tasks of a TPA, where the TPA negotiates with the providers in terms of quality of care, tariff rates, appointment and admission policies etc.., before entering into a contract with them to be empanelled into the provider network. A periodic monitor of the quality and performance of these providers is also essential.
Claims administration: It involves receiving claims, processing claims and accepting/rejecting claims based on the terms of the policy. Once the claim is considered to be genuine and is covered under the benefits of the policy then the claim is settled which is called as claims adjudication.
Information and data management: Data Analytics is highly essential when it comes to designing new products. TPAs by the nature of their work have access to loads of data with which they can generate reports and databases. They act as inputs for management in analyzing and controlling costs besides helping design new products.
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7.6.6 Challenges and Scope for TPAs Incentives for cost control: The remuneration of TPA would generally be a fixed percentage of the policy premium. Reimbursements generally are controllable, but the payments to TPAs for their services are not linked to their effort of controlling reimbursements. Hence, their remunerations should take into account their efforts and successes in controlling the costs and reimbursements. In any insurance system, focus on prevention and promotive services can cut down many costs. TPAs can play an important role in these areas. However, such mechanisms are not put in place and their role is not clearly defined. TPAs can offer and organize such services provided they are incentivized for such efforts.
Educating and improving awareness: In many situations policyholders are not aware of various conditions and exclusion clauses in insurance policies. As a result, disputes between policyholders and insurance companies have increased and both parties have resorted to litigation. Problems arise because of lack of information and awareness, and an inadequate understanding of various nuances of insurance. TPAs can play an important role in educating consumers and bringing awareness. TPAs are the intermediaries between the insurer and the insured and they are in a position to educate the insurer in such aspects.
Mitigating negative consequences & controlling malpractices in health insurance: On the demand side, one positive impact of TPAs existence would be on service utilization. In most situations utilization of high cost speciality care will need approval and concurrence from TPA. Utilization of such services would be rationed by restricting direct access to specialists.
Research on data: While dealing with a large number of policyholders TPAs would be in a position to generate lot of comparable data on utilization of services and their cost structures. This information can be used to set benchmarks for costs and quality of care. However, this might take certain time. Understanding cost drivers is essential in developing and putting in place those drivers.
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Summary Administration of health Insurance includes functions like: Governance functions Management functions Administrative functions Monitoring functions Governance is generally is performed by a regulator body and when it comes to the internal aspects of the company, it is the organizer who performs this role Managerial functions are performed by either an organizer or the insurer or might delegate it to another agency. Management functions of a health insurance are:- Creating awareness about the health insurance Training the staff/community representatives Negotiating with insurance companies Negotiating with providers Fixing the benefit package and the premium Marketing the product Managing risks Controlling costs Controlling fraud Redressing grievances Monitoring the policy Administration is an important component in the smooth operation of the insurance policy. Either the insurer or the organizer takes care of these functions. Administrative functions in health insurance are:- Collecting premium Empanelling providers Authorisation of admissions Processing claims and reimbursements Managing funds Personnel Management MIS Reports for Monitoring Certificate in Health Insurance TCS Business Domain Academy
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Claims are classified into two types:- Cashless Hospitalization Reimbursement Claim Managing the fund involves following tasks:- Budgeting administrative expenses Estimation of Cash flow Investing Funds Different types of professionals in the administrative team are:- Medical Professionals Actuarial/insurance professional Finance/Programme Manager Legal Professional Several metrics used to measure the performance of health insurance are:- Coverage rate Renewal rate Utilization rate Claims Ratio Status of the insurance fund Liquidity Status Solvency ratio Report of the rejected claims Promptness of claims settlement A Third Party Administrator (TPA) is an organization that handles the administrative aspects of a health insurance company that include processing insurance claims or managing employee benefit plans of a separate entity. Network Hospital means a network of hospitals, nursing homes and healthcare providers approved and empanelled by the company and considered as the preferred medical centres or establishments. Cashless Hospitalization means the policyholder will be able to avail of medical services at designated hospitals, and the concerned TPA will settle the bills. Types of Health Insurance Claims are:- Cashless Hospitalization Planned Hospitalization Certificate in Health Insurance TCS Business Domain Academy
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Unforeseen Emergency
Other Services of a TPA are:- Benefit management Medical management Provider network management Claims administration Information and data management Challenges of a TPA are:- No Incentives for cost control Educating and improving awareness Mitigating negative consequences & controlling malpractices in health insurance Research on data
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References Ramesh Bhat, Sumesh K Babu, Health Insurance and Third Party Administrators: Issues and Challenges, Working Paper IIM Ahmedabad, May 2003 IRDA Journal (2003). Data for Health Insurance Managed Care, International Foundation of Employee Benefit Plans Dranove D. (2000), The Economic Evolution of American Health Care: From Marcus Welby to Managed Care, Princeton University Press, New Jersey Managed care in the public sector, US Department of Health and Human Services Jonathan Gruber and Helen Levy, The Evolution of Medical Spending Risk, Journal of Economic Perspectives-Volume 23, Number 4-Fall 2009, Pages 2548 James C. Robinson, The End of Managed Care, American Medical Association
Notice The information given in this course material is merely for reference. Certain third party terminologies or matter that maybe appearing in the course are used only for contextual identification and explanation, without an intention to infringe.