In the event of a medical emergency, the last thing the patient or the family would want is worry about the medical bills or go through the pain of sorting out bills and lodging insurance claims.
There is also this common fear that hospitals tend to take undue advantage of medical emergencies by making the patient go through unnecessary tests or examinations.
The need for professional support services that is needed during the dark hours of one's life is today taken care of by specialists called third-party administrators.
TPAs, licensed by the Insurance Regulatory Authority of India, are nodal agencies operating between the insurer, insured and the service provider i.e. hospitals and nursing homes for rendering smooth delivery of healthcare service.
A TPA is engaged for a fee or remuneration with an insurance company for the provision of its health services.
S K Venkatraman, chief financial officer, Apollo Hospitals says, "The role of the TPA is that of a selling agent. The basic function of the TPA is claim support and back office support to the insurance company. A person contacts the TPA when he wants to buy insurance. One TPA can cater to many insurance companies. It is also mandatory that all policy handling takes place through TPAs."
When a person buys a medical insurance policy, the insurance company passes the details of the insured to the TPA. The TPA issues a photo identity card featuring member's details along with their photograph.
The card identifies the beneficiary as a member of the TPA and assists the member while availing the required cashless services at the preferred provider.
From a TPAs point of view, claims are divided into two categories, the member reimbursement claims and preferred provider claim.
The cashless service, where the insured does not have to pay the bills is available only for PPC.
In the case of an MRC, the insured has to pay the medical bills first and then lodge a claim with the insurance company.
Apollo's FHPL today has networked over 1000 hospitals where the advantages of a PPC can be availed.
The expert case managers attached to the TPA, monitor the health status of the member from admission to discharge and control unnecessary tests and medicines or malpractice.
The case management program provides cost containment services at no cost to the beneficiaries by rendering the following services like monitor healthcare intervention, monitor outcome, prevent fraudulent practice and patient education.
A typical TPA has a team of medical professionals and the technical staff to handle the claims management for the enrolled members.
The claims processing systems are computerised to deal in large volumes of claims, ensuring enhanced speed in processing claims.
Additionally the IT network enables the clients to access the status of claims and make electronic submissions.
There are two distinct variants in the services or products offered by a TPA. Family Health Plant Ltd, a member of the Apollo Group, offers a regular TPA service that is typically backed by an insurance company and also self funded schemes.
Apollo for example has schemes such as Aragonda, where insurance cover is given for Re 1 a day.
"We also have a micro health insurance scheme for 17 lakh farmers in Karnataka. Each farmer pays Rs 5 per month and the insurance covers the cost of any surgery. So far surgery costs of 2000 patients has been covered by this insurance in the last 3 months," says Venkatraman.
Under the self-funded scheme, FHPL creates a fund, which is a pool of money collected from its members.
The Arogya Bhadratha Scheme -- a self funding scheme for Andhra Pradesh Police force covers 345, 000 lives for providing assistance in designing and administering the secondary and tertiary healthcare needs.
FHPL has implemented the scheme for four years and has contributed to the funds by saving 25 per cent of the annual allocated funds.
Most of these self-funded schemes are customised to suit the needs of a collection of members.
Typically corporates can design their own scheme to suit its employees. This is quite similar to the group insurance schemes offered by insurance companies and have been in use for quite some time.
Venkatraman says, "In India the system of health insurance is yet to stabilise. Market education about health insurance has been low. However, over the last couple of years, premium on health insurance has doubled, which is an indication that the concept of health insurance is really taking root in India."
Today, there are 20 TPAs licensed by Irda. FHPL, based out of Hyderabad is one of them. For the complete list of licensed TPA visit http://www.irdaindia.org/tpalist.htm.
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