Page 31 - The Insurance Times August 2024

and have influence on controlling the cost only if they are TPAs. All stakeholders- TPAs, providers, insurers , regulator
themselves qualified and know the complexities of various and the government need to collectively address this issue
healthcare procedures and treatment protocols of health to increase awareness about the functioning of TPA and the
insurance contract. Properly trained personal would further process involved for availing the Cashless service by the
make data capturing accurate and effective for various customers. Unless the customers are educated enough of
stakeholders. Besides technical knowledge, soft skills and the services offered, the services will remain unutilised. The
proper behavior of the personnel dealing with customer recent initiatives of "Cashless everywhere" and time lines
would result in reducing grievances and customer for issuing Pre-Authorization in one hour and final approval
satisfaction. within 3 hours of receipt of discharge authorisation request,
needs to be publicized widely to create awareness amongst
Proper knowledge of the various health insurance products, the customers.
their benefits and claims processing is also extremely
important for the staff at the Providers desk who deals with Conclusion
the TPAs officials.
Today, a number of customer services are being provided
by the TPA's and 75% of the total number of health
d) Embracing Technology along with human
insurance claims are being paid through them, they are the
interface custodian of Insurance Company's repute, they need to bring
Embracing technology to provide highly attentive and in more professionalism in their approach to hallmark
prompt service to the insured customers is very crucial for customer satisfaction and control cost. Training and soft skill
the TPAs and Insurers. Investment in tech tools like mobile development at the TPAs end, developing their network and
apps, online portals and chat bots has become essential to relationship with the providers to provide appropriate quality
empower the customers to communicate with the TPAs in care at reasonable cost are inevitable to gain the trust of
no time to file a claim through scanned documents and know the Insured customer . The success of health Insurers
the status of the claim. Many forward looking TPAs are ultimately depend on the prudence , precision and skills of
leveraging technology for data analysis, Machine learning claim management to the satisfaction of their customers
and automation to deliver better services. With more use either in-house or through TPAs. Thus, TPA and Insurer needs
of AI /ML better solutions and services are expected from to bring in more transparency, competition , cost
the TPAs by Tech-savvy customers.
containment and better services.
Technological disruptions are vital for streamlining the claim
process promptly but Insurance services will continue to Implementation of the new health insurance rules from
require human intervention to provide a hassle free August 1, 2024 will ultimately rests with the way the TPAs
experience to the hospitalized customer. For instance in function and adopt technology to comply with the time
frames specified. More stringent regulations and monitoring
situations where the primary insured is himself hospitalised
and critical , he could not access the messages sent by TPA/ for TPAs is imperative to achieve and manage 100% claims
Insurer related to queries for requirement for issuing the through cashless mode.
Pre-authorisation letter. His caregivers needs to be
approached by the TPA/Hospital Desk for such issues. These Bibliography
small communication gaps are the cause of all delays, IRDA report 2021-22.
leading to prolong treatment and delays at the time of IRDA report 2022-23.
discharge when the patient has to wait for hours to get the Health insurance data analysis report 2019-20,
approval from the TPA/Insurer. Insurance information bureau of India.
IRDA's Third Party Administrator -Health Services
Moreover, many senior citizens and illiterate people who are
Regulation,2016
not tech savvy will always require a human interface in the
claim process Master Circular on IRDAI (Insurance Products)
Regulations 2024- Health Insurance dated 29.05.2024
e) Increasing consumer awareness and https://www.thehindubusinessline.com/money-and-
educating the customers banking/ accessed 30.05.2024
There is less awareness about the service provided by the https://irdai.gov.in

The Insurance Times August 2024 29