What is TPA?

Health insurance can be complicated, with terms and processes that leave people confused, especially when it comes to claim settlements. One such term you may encounter is TPA. It’s an essential player in the health insurance ecosystem, ensuring that claims are processed efficiently. In fact, 72% of all health insurance claims in 2023-2024 were settled through TPAs. That's nearly 1.92 crore claims!

In this blog, we’ll take you through 

• What TPAs are 
• How TPAs work 
• The risks involved 
• What you need to know when dealing with them.

Let’s get started. 

Worried about delays or poor service from TPAs? We’ll help you choose a policy with in-house claim settlement. Book a free call with Ditto now!

What is the Role of TPA in Health Insurance?

A Third-Party Administrator handles administrative tasks between the insurer, the insured, and the hospital. Their primary responsibility is to ensure that the health insurance process runs smoothly, particularly during the medical claims process.

Key Functions of a TPA include:

1. Processing claims (both cashless and reimbursement). 

TPAs manage the paperwork, documentation, approvals, and communication involved in claim settlement, all as per the insurer’s guidelines. However, they do not decide claim outcomes.

2. Hospital coordination

TPAs assist insurers in managing hospital networks by coordinating with hospitals. However, the final empanelment decisions are made by the insurer.

3. Emergency Support

In times of medical emergencies, the TPA acts as a point of contact, guiding the insured through the claims process.

4. Maintaining Records

TPAs issue health e-cards with unique IDs and maintain comprehensive digital records of claim history, medical documents, and approvals.

5. Data Analysis

Over time, the collected data becomes a valuable repository, helping to identify patterns in hospitalization, treatments, costs, and even potential fraud. These insights are often shared with insurers to improve underwriting, product design, and risk management.

6. Managing Hospital Networks

TPAs are responsible for regularly adding, monitoring, and evaluating empanelled hospitals to ensure consistent service quality.

In summary, TPAs are significant contributors to the efficiency, transparency, and intelligence of the health insurance ecosystem.

How Does a TPA Handle Claims?

Here’s a breakdown of how TPAs manage the claims process in health insurance:

1. Cashless Treatment:
   • You show your health/policy card at a network hospital.
   • The TPA coordinates with the hospital and insurer to obtain pre-authorization.
   • The TPA sends an approval code to the hospital, and the insurer settles the bill directly.
2. Reimbursement Claims:
   • You pay the hospital upfront for treatment.
   • Afterward, the TPA reviews your documents and medical bills and sends them to the insurer for approval.
   • Once approved, the TPA processes your reimbursement and sends the amount directly to you.

The TPA also provides continuous support to ensure the process is smooth and timely. Next, let’s look at the most prominent TPAs in the country.

Popular TPAs in India and Their Hospital Network

Here’s the list of the TPAs in India so you can become familiar with them:

What Is the Process of Cancelling TPA in Health Insurance?

If you’re unhappy with the TPA assigned by your insurer, it’s possible to request a change. However, it’s not always a straightforward process. The steps generally include:

1) Check Policy Terms: 

Review the terms and conditions of your policy to determine if the insurer allows you to switch to a different TPA. 

2) Contact the Insurer: 

Contact your insurer to request a change. They may offer you a choice of alternative TPAs. 

Note: Some insurers require a written request or a filled form at the time of renewal to change or cancel the TPA. You can mention: "I would like to opt out of the services of the current TPA [TPA Name] and request direct claim servicing by the insurer (or a different TPA, if preferred)."

3) Provide Valid Reasons:

If the insurer allows changes, they may require valid reasons for switching (e.g., poor service, delays in claim processing).

4) Follow IRDAI Guidelines: 

According to IRDAI guidelines, insurers are required to consider a policyholder’s request for a TPA change at the time of renewal. However, TPAs are usually assigned based on the policy or insurer's location, and changing one might not always be an option.

What Are the Risks Involved with TPA?

While TPAs help simplify the claims process, there are some risks you should be aware of:

1) Delayed Claim Processing:

TPAs may not always offer the same speed or responsiveness as an in-house claims team. As a result, claims may take longer to process, leading to frustration during emergencies.

2) Service Quality:

The quality of service can vary widely depending on the TPA. Some TPAs may have poor customer service, resulting in delays or incorrect information. They might also need frequent follow-ups, which can take up a lot of time.

3) Limited Control:

Since TPAs are intermediaries, you may not have direct control over the approval or rejection of your claim. This can cause confusion and frustration when you need quick approvals.

4) Inadequate Network:

While TPAs typically have extensive networks, some insurers or TPAs may have limited hospital partnerships in rural or tier-2 cities, thereby reducing access to care.

Ditto’s Take on TPA in Health Insurance

At Ditto, we believe that understanding how TPAs work is crucial for navigating your health insurance effectively. While a good TPA can smooth out the claims process, an inefficient one can lead to stress and delays when you need assistance the most. 

Here’s our advice: Insurers with an in-house claims team are often a better choice. 

These insurers manage the process end-to-end: they're faster, more accountable, and have better control over service quality. No middlemen. No passing the buck. You deal directly with your insurer, which can mean faster approvals, smoother hospital coordination, and significantly less hassle.

Before buying a health insurance policy, always check:

• Does the insurer handle claims in-house or use a TPA for retail (individual) health insurance policies?

Note: Most retail health policies will also mention this in their brochures, whether they follow in-house claim settlement or not, primarily because it's a positive marketing point for them.

• If there's a TPA involved, who is it? What are their reviews like?
• Is your preferred hospital in their network?"

Bottom Line: While a top-notch TPA can still provide decent service, nothing beats the efficiency and peace of mind that comes with an insurer that handles claims itself. 

Why Talk to Ditto for Your Health Insurance?

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Conclusion

TPAs play a crucial role in the functioning of health insurance in India, assisting policyholders through the claims process, coordinating with hospitals, and ensuring cashless treatment. However, their service quality can vary, and it’s essential to be aware of the potential risks involved.

To avoid unnecessary delays and confusion, always research your TPA before purchasing a policy. Ideally, choose insurers that handle claims in-house for faster resolution, but if you’re working with a TPA, ensure you know their reputation and the services they offer.

Frequently Asked Questions