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Focus
Tackling Teething TPA Problems
The Third Party Administrator unit in a hospital is meant
to facilitate transactions of patients' cashless facilities. Priti Pathak
takes a look at how hospitals can manage this unit effectively
 One
of the main activities of the marketing department of a hospital is to tie-up
with different TPAs for provision of credit treatment facility or cashless service
at the hospital, which are reimbursed by the party concerned, at a later date.
The services provided by them include cashless service at hospitals, telephonic
support to policy-holders and management of claims and reimbursements. They
also provide services to the corporate sector in designing and managing health
benefit packages for their employees. The main function of a TPA is to guarantee
cashless hospitalisation to policyholders. In short, TPAs are a key link between
insurance companies, healthcare providers and policyholders.
"The common man of today is becoming more and more knowledgeable about
healthcare and the insurance sector. The number of patients and the percentage
of revenue from insurance companies are rising steadily. Thus, it is increasingly
getting very important for any hospital to have its own TPA department,"
says Dr Atamjot Grewal, Head of Medical Services, Artemis Health Institute,
Gurgaon.
Having a TPA for any hospital is beneficial as the hospital gets a huge chunk
of its revenue from the insurance companies. "It is a significant revenue
channel contributing between 15-18 per cent of revenues for large corporate
hospitals," shares Sanjay Rai, Director- Sales and Marketing, Max Healthcare,
Delhi.
Patients, who earlier thought of postponing their treatments or surgeries because
of cost factors, now can easily get themselves admitted with their medical insurance
to take care of the hospital charges. But on few occasions, it has become a
nightmare for the hospital authorities to collect the outstanding bills from
different TPAs. Research shows that in few hospitals, the outstanding bill from
cashless transaction has crossed crore of rupees. So, it has become important
for the hospital authorities to focus more on receivables management. A study
conducted at Bangalore based Manipal Hospital and New Delhi based Escorts Heart
Institute revealed that some specific issues create confusion and complexity
to the whole process of credit billing and thus contribute towards outstanding
bills for the hospital. Perhaps, it is very important for any hospital set-up
to streamline its TPA department and take necessary measures to deal with the
above mentioned problems and ensure its smooth functioning.
Pre-authorisation
Pre-authorisation not taken from the concerned corporate / TPA is an issue.
Normally, when a patient gets admitted, an estimate is prepared based on his
medical requirements and sent to TPA for pre-authorisation. The TPA then sanctions
whatever amount based on the estimate. Sometimes, the TPA takes time in sanctioning
this first estimate. The later the sanction, the more problematic becomes the
recovery for services already rendered. Further, there are chances of errors
in the pre-authorisation letter like mistake in the date of authorisation. Patients
do not carry identity cards or there are instances where patients do not furnish
sufficient medical details for pre-authorisation by TPAs. Also, patients do
not go through the information brochure sent by TPAs leading to inconveniences.
Many patients come with their expired insurance policy.
Patients/ relatives give wrong information (wrong address)
Patients address is changed.
Patients/relatives do not understand the complexity of the whole process
of the cashless service.
Patients file wrong details in the pre-authorisation form making delay in
the whole process of cashless transaction.
Patients refuse to pay additional amount above the approved credit limit
by the TPA for certain procedures/treatment etc in hospitals. |
Error in Making Records
Improper recording of the patient details like employment ID, name, sex, address
and so on are the common errors. If the patient is admitted in an emergency,
there are times when the emergency certificate is not made by the casualty medical
officer. This leads to inconvenience and recording of incorrect information.
Problems also occur when the patient admitted in emergency fails to get the
authorisation for the treatment from the concerned employer.
Patient Awareness
There are instances when the patient only comes with just the TPA card and no
identity card along. Thus, it becomes difficult to refuse the patient for the
treatment. In some instances, the patient (policy holder) is 'ignorant' about
the nature of insurance policy he/she possesses, like how much cover is available
to them, list of inclusions and exclusions, as well as any capping in their
policy. This leads to several problems at the hospital end and sometimes leads
to procedural delay.
| Few recommendations that will facilitate smoother
transactions:
Receivable Management:
- It is an important aspect for a hospital
in the current scenario to minimise bad debts.
- The hospital needs to send the bills on
time. Delay in the bill dispatch process will create delay in receiving
the amount from the concerned authority.
- While dispatching the bills to the TPAs,
there is a need to mention the corporate employee's name and ID in the
bill, so that there is no confusion, if the relatives of the corporate
employee avails the treatment.
- TPAs need to be informed that while they
send the cheque, they should mention in a letter the bill number for
which they are settling the bills.
- After dispatching the bills to TPA, the
record of the delivery should be maintained and there is a need to make
a courtesy call to the corporate in next few days, to ensure
that the TPA have received the bills.
Maintaining Neat Records:
- While making tie-ups with the corporates, the address of the office
to which bills should be sent (as many corporates have many offices
in the same city) should be made clear. Constant follow-up with the
corporates/ TPA needs to be done after bill dispatch.
- While dispatching the bills, a letter can be sent mentioning names
of all the documents the hospital is providing along with the bill.
It can be pre-typed and while dispatching 'yes/no' can be ticked accordingly.
- Hospital should constantly update the names of the contact person
in the corporate office/ TPA.
CRM
- Someone within the hospital should be assigned the responsibility
to constantly maintain a relationship with the corporates- Customer
Relationship Management (CRM).
e-Transfers
- An option of electronic transfer can be tried out for clearing of
the bills.
- Corporates can be asked to use electronic transfer as a payment option
and send details of the payment by email/ telephone. If possible, an
additional 0.5 per cent or a fixed amount can be given discount against
the bills.
Definite Protocols:
- TPAs should have a well-defined set of
protocols for handling health insurance.
- During misplacement of bills in dispatching
from the hospital or from the corporate office, a protocol should be
decided whether the corporates would accept the photocopy of
the bill.
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Discharge Time
 "It
is a significant revenue generating channel contributing between 15-18 per
cent of revenues for large corporate hospitals"
- Sanjay Rai
Director- Sales and Marketing
Max Healthcare, Delhi
|
 "A
standard procedure for all the TPAs would help both the TPA and the hospital"
- Major General Vijay Krishna
CEO
Breach Candy Hospital
Mumbai
|
 "If
the insurance company reimburses the cost at which the hospital purchases
the device, then we suffer loss"
- Dr Krishna Reddy
CEO
Care Hospital, Hyderabad
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When it comes to problems that occur while a patient is getting
discharged, there can be a delay in finance clearance in the hospital. This
causes unnecessary loss to the hospital since the patient has already been discharged.
The other problem is of the patient being discharged without taking his/ her
relative's signature in the discharge certificate, thus inconveniencing the
hospital authorities in handling the further process and recovering the claim
amount from the TPA.
Some of the other causes of the same problem include medical
record incompletely filled by the treating doctors, discharge summary not signed
by the treating doctor, remarks not mentioned in the discharge summary, final
bill more than the approved amount and delay in enhancement approval. Most often
'delayed response' from the TPA on 'final authorisation approval' is an area
of concern. TPAs generally take two to three hours to finally authorise a claim
whereas the hospital internally takes around two hours to complete the administrative
formalities that encompass discharge summary, collection of reports, billing
and other relevant documentations.
In totality, patients have to wait for around four hours
for discharge. "TPAs also put limitations on the room rent and add other
clauses and they sanction only a percentage of the estimate," says Dr Grewal.
Normally, if the bill is within the sanctioned amount, the patient does not
face any problem. However, if enhancements are required, the enhancements get
delayed from the TPA, thus increasing the bedtime of the patient. "Different
TPA has different clauses and calculations, which is time consuming and causes
delays. A standard format/ procedure for all the TPAs would help both the TPA
and the hospital," says Major General Vijay Krishna, CEO, Breach Candy
Hospital, Mumbai.
Billing Hours
Incorrect billing done (specific discounts/ rates not followed
as per agreement with the corporates/ TPA), patient signature not taken on the
final bills and improper recording of the details are some common errors. When
it comes to final billing, the patient needs authorisation from the TPA on the
billed amount, which at times gets delayed and also the TPAs have their own
criteria of including and excluding certain costs mentioned in the final bill.
This means that the patient has to settle whatever has been excluded by the
TPA and then they can leave the hospital.
Dispatching Issues
Hospital also faces problems while dispatching the bills to TPAs when all the
relevant documents are not attached while dispatching (reports of laboratory,
blood bank, imaging, document of approval from the TPA), cover note not prepared
with the bills, bill dispatched to the wrong address, bill dispatched to the
different office of the same company (some bills need to be dispatched to the
office where the employee is working and not the corporate office), delay in
dispatching the bills, bills getting misplaced in the hospital and further clarification
regarding treatment is required by the TPA.
The other problems attached to this category is after the bill is dispatched
the confirmation regarding bill receipt is not made with the TPA, employee name/
ID not attached with the bills, so sometimes if employee's relative avails any
treatment then it is difficult for the TPAs to trace the employee relatives
who has taken the treatment and in the process the payment gets delayed. Sometimes,
the concerned employee may change jobs or retires and any written correspondence
with him goes in vain, which requires constant upgradation of the database in
the hospital.
Problems also arise in terms of accounts and maintaining records after receiving
the bills. Sometimes, the corporates make payment for many bills all at a time
without a cover note, and it becomes difficult for the finance department personnel
to trace, which bills are cleared by the TPA. Wrong entry made in the computer
recording, for example wrong entry of the Immuno Polymorphism Database (IPD)
number, employee name, bill number, wrong entry of the employee office all create
confusion.
Problems at the End of TPAs
Some issues that come from the TPA's end would be delay in giving the authorisation
for the treatment on behalf of the TPA, wrong entry of the employee/customer
details, or misplacement of the bills by the TPA. In few cases, it was found
that the employee retires/ resigns/ change jobs and whereabouts details are
not available with the past employers, and if any query arise while settling
the bills, it is not solved and the payments get delayed.
Sometimes, the TPA delays the payment of the bills for no valid reason. It was
found that many TPAs delay payment because of lack of fund with them. There
are instances where TPAs re-look the entire case of the patient and this further
delays the final settlement.
As far as recovery of the hospital dues from TPAs are concerned, the most common
problem is the delayed payments. "The reason provided by TPAs is that there
is delay in getting 'floats' from their parent insurance companies. The other
issue is one of 'deductions' which sometimes is not justified," shares
Rai.
There is a clause with the insurance company that they would reimburse the cost
of the device at which the hospital has purchased it. Due to this, the hospital
has to incur losses because then they do not consider the other costs which
are involved relevant to the device. The other kinds of costs are the logistic
charges, inventory costs, investment on skill and technology for handling the
device and so on. "If the insurance company reimburses the cost at which
the hospital purchases the device then we suffer loss. The other investments
should also be considered which is borne by us. Otherwise, this would lead a
hospital to either stop the practise of cashless service or falsify the costs
which would be unethical and go against the hospital," opines Dr Krishna
Reddy, CEO, Care Hospital, Hyderabad.
Uniformity and Awareness
"There should be uniformity across all the TPA groups in terms of the norms
and the tariff structure," opines Dr Reddy. There has to be uniformity
in the billing model for all the hospitals so that there is transparency between
the hospital and the TPA groups. With this practice the chances of delay is
reduced and it also smoothens the claim process. Bringing awareness to the policy
holders (patients) about the services that they can be facilitated is a necessity.
TPAs should hold seminars to educate the stakeholders on the evolving changes
in the health insurance sector.
IT- Need of the Hour
IT is the need of the hour which would be helpful in the effective management
of the claim settlement process. A software should be developed for document
submission which could be accessible to both the TPAs and the hospitals. Therefore,
all the paper work could be maintained on the web and reduce the instances of
mishaps like loosing the claim documents and so on.
A Long Way to Go
There is a lot that needs to be done to streamline the functioning between TPA
and insurance companies. Currently, the TPAs are placed on the defensive by
the insurance companies for not delivering against what they have been appointed
for. This includes curtailment of claim costs and customer satisfaction, whereas
on the other hand TPAs have not been given enough authority to deliver best
results. TPA is an evolving business in India and with time it needs to be more
seamless for the benefit of the patient and the hospital.
healthcare@expressindia.com
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