Challenges in dealing with TPAs Role of TPA Challenges for a policyholder in availing services of TPA • Rely more on their insurance agents • Low awareness- about the existence of TPA • Very little knowledge about the empanelled hospitals- cashless hospitalization services Challenges faced by hospitals Industry views • Hospital administrators- high burden in terms of effort and expenditure after introduction of TPA • No substantial increase in patient turnover after empanelling with TPAs Delayed initial sanction • Mandatory- prior in principle approval (except accident-related claims) • Delay in sanctioning first estimatethe later the sanction the more difficult the recovery for services already rendered. TPA policies • Insistence on standardization of medical services/ procedures across providers • Different TPA different clauses & calculations time consuming and causes delays • Final billing- TPAs have own criteria of including and excluding certain costs in the final bill Delay in final clearance • ‘Delayed final approval‘- 2-3 hours increasing discharge time • Limitations on the room rent and other clauses • TPAs sanction only a part of the estimate- any enhancements cause delay • Unnecessary loss to the hospital since the patient has already been discharged Errors • Errors in the pre-authorisation letter like mistake in the date of authorisation • Improper/wrong recording of the patient details like employment ID, name, sex, address etc. • Misplacement of the bills by the TPA Problems while dispatching bills • All the relevant documents & reports not attached (reports of laboratory, imaging, approval letter from the TPA) • Cover note not prepared with the bills • To the wrong address • Delayed dispatch of bills • Bills misplaced in the hospital Delayed payment • Research- in few hospitals, the outstanding bill>1 Crore of rupees • Reasons Lack of fund with TPA Re-look the entire case- delays the final settlement • Unjustified deductions Financial impact Delayed payment Blockage of huge sum of money Loss of interest & operational problems for hospital ? Suggestions • Send the bills on time • Answer TPA queries promptly • Beneficiary's name and ID in the bill to avoid confusion • Hospital- constantly update the names and contact number of the contact person in the TPA Suggestions • A record of the delivery of dispatched bill • Follow up call- check bills received • Uniformity in the billing model for all the hospitals • Reminders for payment Suggestions • Improving awareness- Seminars by TPAs for stakeholders • A software can be developed for document submission – accessible to both the TPAs and the hospitals – all the paper work on the web – reduce the instances like losing the claim documents • Common coding methodologies- consistent information Suggestions • Stop cashless for patients- payment defaulters till payment is made • Good rapport- hospital marketing department & TPA • TPAs - when sending the cheque, must mention the bill numbers for which payment is being made
