Everything You Need to Know About TPAs in Health Insurance

Everything You Need to Know About TPAs in Health Insurance

Do you have an idea of how many people die due to the dearth of acute health care? Very often we come across cases wherein people lose their loved ones, just because they are unable to arrange funds for their expensive medical treatment. Given the ever rising costs of health care and the plausible benefits offered by the insurance sector, people have now started to invest in health insurance policies.

These arguments are not on flimsy ground, but are the outcome of a detailed research work done by McKinsey’s Global Insurance Pools (GIP). The organization works on Proprietary Markets’ Database that comprises of about 150,000 data points that are picked from 64 countries across the globe; and it covers around 99 percent of the insurance premiums that exist across the globe.

Sidelining the potential regulatory and macroeconomic threats, McKinsey’s GIP predicts that the insurance sector will experience a whopping growth of 6.3 percent from 2014 to 2020. When compared to the growth of last decade which was reported on 2013, it was estimated that this decade will surpass it by 2.8 percent.

To provide a seamless treatment procedure to those who are already going through physical as well as mental pain because of an ailment or injury, the insurance providers offer cashless facilities and ease the adverse conditions that people face because of lack of funds. This was the sole motivation running behind the innovation of TPAs in health insurance sector. Moreover, the growth of TPAs in health insurance sector can be judged from the Total sector employment as of April 2016 which was a noteworthy 175,000.

This makes Third Party Administrators not only a force to reckon with, but also makes it the most convenient tools for insurance that we have so far.

Now that you are convinced that TPAs have grown conveniently, we will further discuss what they are, how they function, and what are the benefits offered.

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TPAs in Health Insurance: At a Glance
As discussed above, during of any medical emergency, you just need to take care of your ill family member or friend, and the rest shall be taken care of by your TPA. All in all, TPAs look after the payment of your hospital bills and claims made with respect to them in the future. This is the basic function of a TPA; however, read on to know more about TPAs.

Cancellation of TPAs in Health Insurance
A TPA does not have a say in being appointed or dismissed as your TPA; it’s something that your insurance provider decides. All the insurance takers need to assimilate this information because if in case you encounter any issues regarding the health insurance claim settlement then you need to visit or contact your insurer and not your TPA. However, you need to note that if there is an issue with the process of claim, then the TPA shall look after it.

Service Related Issues:
In case of service related issues, you need to contact your insurance provider instead of your TPA. For instance, if the TPA is taking more than two days for processing your claim even after completion of documentation process from your end, then you need to contact your insurer.

Insurance companies are responsible for communication all the changes, with respect to TPAs, to its customer. And the TPAs must provide a full-fledged customer support and answer the queries of the policy-owners. TPAs must deliver a complete guide to all the insurers individually; that renders all the information about providing complete support and assistance.

TPAs do not Charge for the Services they Provide.
In case of Cashless Claim Facility, the hospital coordinates with the TPA in order to seek authorization. To seek a cashless claim, you just need to carry the valid policy proofs along with an identity proof to the hospital. However, you must know that there are few scenarios mentioned below when the hospital does not support cashless treatment:

Missing or incomplete details of hospitalization
Diseases not covered under the policy
Thus, this facility saves you from paying your hospitalization bills at the time of discharge and thus, helps you get a hassle-free treatment. Additionally, the TPAs also offer you a referral to ambulance, surgeons and specialists.

When you buy a health policy, your insurer provides you with a kit containing a Guide Book and a List of Network Hospitals. Moreover, you can also get to know about the TPA’s from their official website.

The waiting period under any health insurance policy is about 30 days, meaning, any disease happening or being diagnosed in that period shall not covered under the policy. However, any accident that takes place in the initial 30 days of the policy shall be covered.

Another benefit of having a TPA as the first point of your contact is that it allows you to switch to another hospital during any ongoing treatment, if the need arises. However, this shift shall be scrutinized by the TPA on the basis of the scenario and as per the terms and conditions of the policy.

In case you fail to provide the complete information in the hospitalization form or you are not sure about the history of the disease, then you would not be able to avail the cashless facility. In such cases the TPA would not be able to help you and you would have to go through the usual claim process eben in a network hospital.

In order to leverage cashless facility, you need to visit any of the network hospitals that fall under the network group of your insurer. If you wish to be referred to a network hospital, then you must present the following documents to your. On the basis of these documents the TPA can issue him/her preadmission authorization for a cashless facility.

An original prescription from the doctor, comprising of a detailed description of the symptoms of the disease, as diagnosed, on the letterhead of an authorized medical practitioner.
Hospitalization form in the as mentioned by the insurer.
Details of the old policy, if the TPA does not have a copy of it.
Opting for a cashless facility totally depends on your discretion and is not a compulsory facility. So you can either choose a cashless facility or opt for a reimbursement. However, looking at the advantages offered by cashless claims it is advised to go for it; especially, if your hospital falls under the group of network hospital. Doing so will generate a financial support as you would not need to pay your heavy medical bills and the same funds could then be used to tackle the post-hospitalization expenses.

Benefits of a Health Card
One of the most apparent benefits of using a health card is that it allows the insured and his/her family members to avail medical facility from any of the network hospitals, under your TPA, without having to pay your medical bills and later on run around to get your claims settled.

To sum it up, you must always be prepared in advance so as to tackle with any of the adverse situations that may arise in life; and seeking a TPA’s support is one such step that empowers a policyholder to overcome a haphazard situation.

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