Health+Insurance+n+TPA

8/6/2019 Health+Insurance+n+TPA

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HEALTH INSURANCE

&THIRD PARTY ADMINISTRATION

Presentation By-Muneer Trivedi


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Wh at is Healt h Insurance ???Health insurance means risk coverage to providefinancial shelter in the event of medical treatment incurred out of a sickness.

Health insurance is one of the fastest growingareas in the insurance industry and is expected togrow to Rs.30,000 crores in 5 years from thecurrent Rs. 8,100 crores.


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Wh y is Healt h Insurance

important?Rising medical costsSh aring of h ealt h related risk

uncertain h ospital billsExpensive/quality h ealt h care servicesMoney value Sick Vs Healt h yFamily h ealt h insuranceTax benefitProductivity of workforceRemoves some of t h e burden from t h e stateKeeping pace wit h t h e customer needs w h ileac h ieving profitability


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Th e Indian Healt h ScenarioT otal Expenditure on health in India is nearly 6% of theentire GDP

Private health care expenditure is 4.25 % of GDP. At present the insurance coverage in India is negligible.Over the period the private health care expenditure hasgrown at the rate of 12.84 % per annum.

Indian health insurance industry stands at INR 8,100crores with only a small Section of the total population(around 2%) being covered so far.CAGR of around 35 % (FY2002-08)


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Source: Business World (India)Source: Business World (India) Oct 2007Oct 2007

Low penetration of Insurance and Low Govt. expenditure in India . . .Low penetration of Insurance and Low Govt. expenditure in India . . .Has resulted in high Out Has resulted in high Out- -of of--Pocket spendPocket spend

Uninsured82.65%

CommunityInsurance

4.19%

Pvt. sector Enterprise (Self

Funded)

4.61%

Indian Railways0.59%

Pvt.Health

Insurance1.42% CGHS3.35%

ESIS3.19%

Uninsured82.65%

CommunityInsurance

4.19%

Pvt. sector Enterprise (Self

Funded)

4.61%

Indian Railways0.59%

Pvt.Health

Insurance1.42% CGHS3.35%

ESIS3.19%

Health Insurance Penetration in IndiaHealth Insurance Penetration in India


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Perceptions about Healt h

Insurance in IndiaWh at is INSURANCE ? Buying a Promise


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Healt h Insurance: KeyStake h olders

Health InsuranceIndustry Government

Distribution c h annelpartners

NGOs / SHGs /MFIs

Media /Telecom

Customer

InsurancecompaniesTPAs

Healt h Providers

IRDA -regulator


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Introduction to Healt h

Insurance PolicyProvided by both private and public Cos.

Voluntary medical insurance program that providesfor reimbursement of hospitalization/domiciliaryhospitalization expenses/disease suffered/accidental injuries sustained during policy period.

Includes :Family floater (for families) mediclaim.Healt h insurance or mediclaim for individuals and for seniorcitizens.Overseas travel insurance.


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Mediclaim PolicyInstituted in 1986.Eligibilty criteria - 5 to 80 years of age.

Premium depends on age and sum insured.Benefits hospitalization benefits from Rs.15000 to

a maximum of Rs. 5,00,000.Providers any hospital with 15 beds or moreExclusions any pre-existing diseasePayment mode reimbursement of bill by Co. or by

T PA is also possible. (premium 6%)


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Need For H.I Policy According to Money Digest 2003:

1 in 3 person will develop some life threateningcancer.1 in 4 person will contact heart disease before they

retire.1 in 20 person risk the chance of having strokebefore the age of 70


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Need For H.I Policy contd According to World Bank Report:

85% of the working population in India do not have Rs.5,00,000 as instant cash.14% have Rs.5,00,000 instantly but willsubsequently face financial crunch.Only 1% can afford to spend Rs.5,00,000 instantly

and easily.99% of Indians will face financial crunch in case of critical illness.

H ence the need for H ealth Insurance .


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Wh o does not need H.I???One who is covered by his employer.

One who can make immediate payment of hospital bills of the order of Rs.1,00,000 orRs.2,00,000 or even Rs.5,00,000 need not to go for health insurance.


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Wh at H.I Policy covers in

India?It covers hospitalization when a patient is in hospital for more than 24 hoursdue to:

-Illness-Accident -Surgical requirement


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COSTS COVERED ARE:Room, boarding expense inhospital/nursing home.Nursing and ICU expendituresFees of healthcare professionalsinvolved in the treatment

AnaesthesiaPre and post hospitalization expenses.


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Wh at H.I Policy in India

does not cover?T reatment of illness at home byconsulting doctor in your locality oreven in hospital.Health check-ups,home health services.Long term care/rehabilitative carePreventive healthcareDental and vision servicesOutpatient services


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Healt h Insurance PlansHealt h Insurance

Plans

Private Social Community Based /Micro Insurance

Risk Rated &Risk Rated &offered byoffered by

CommercialCommercialOrganizationOrganization

NonNon-- RiskRiskRated &Rated &

GovernmentGovernmentinitiatedinitiated

CommunityCommunityRated &Rated &NormallyNormally

managed bymanaged byCommunity /Community /

GroupsGroups


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Existing Sc h emes Can Be

Categorized As:(1) Voluntary health insurance schemes or

private-for-profit schemes;

(2) Employer-based schemes;

(3) Insurance offered by NGOs / community

based health insurance ( CBHI), and(4) Mandatory health insurance schemes or

government run schemes

(namely ESIS, CGHS).


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THIRD PARTY ADMINISTRATION

T PAs are BPO of insurance companies andare responsible forcoordinating all aspects

of claims arising due tohealth insurance policies.

TPA

Insurance

company

PolicyHolder Hospital

premium reimbursement

Healt h services


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Services provided by TPAI.D Card24 hours helpline for customer servicesProviding list of hospitals in networkClaim processing during admission of policy holderEnquiryScrutinizing bills


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Functions Of TPACoordinates with insurance co. & hospitalMaintains all recordsEnrollment processingIssues authorization forms to the hospital

Makes the payment to the hospitalFacilitates claim settlement Fund administration

Benefits management


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Procedures Facilitated by TPACashlesshospitalization

Reimbursement

Enhancement

Claim settlement


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You require hospitalization

Planned Emergency

T PA scruitinizes & on case tocase basis authorizes mediclaim

Appro al granted & you get cashless hospitalization

You get treated & prior to dischargecomplete claim form and sign all bills

Pay all non-medical bills byyourself

T PA pays bills of appro edamount to the hospital

Appro al not granted ,nocashless hospitalization but claim papers can besubmitted for reimbursement

Planned & emergency billsare paid by you. claim to besumbitted to T PA withoriginal documents

Network hospital Non-Network hospital

CASHLESSHOSP.


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REIMBURSEMENTPatient pays total bill to the

hospital

After discharge submits all the originalbills+original discharge summary+original

investigative reports to T PA

Patient is reimbursed within30-60 days

Claim studied by T PA


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ENHANCEMENT:In case the bill exceeds the approved

amount, the ward coordinator sends thefinal bills and documents to therespective T PA for enhancement.


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CLAIM SETTLEMENT All documents of patient are sent to T PA

No discrepancy

T PA studies the claim

Discrepancy found

Claim settled within30-60 days

Queries on them are

asked

Resolved withhospital

Claim disapproval ordenial

Not resolved


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PROBLEMS :FACED BY TPAs :

Lack of proper communicationIncreased bill and treatment cost Hospitals show negligence in filing the claim procedureLack of trained staff and professionals

FACED BY HOSPITALS :

Lack of awareness of the procedureIssue of pre-authorization letter not within specified timelimit Claim reimbursement is also unnecessarily delayed in some

cases.


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Healt h Insurance Focus

AreasHealth Insurance - potential tobecome a Rs.25000 crores industryby 2012.

No. of Elderly People in theDeveloping World will T RIPLE in25yrs. (WHO)

In India, the no. of people above 60yrs is about 8% today, with that no.expected to hit 21% by 2025 . (AsiaInsurance Review)

Source: NIA Library


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Healt h Insurance T h e W ay

Ah ead

Creating awareness on Rights& ResponsibilitiesStandardization of Cost

T PAsHealth Providers

Increased T ax benefit Removal of Service T ax


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Healt h Insurance T h e W ay

Ah ead contd

Gradation of Health service providers

Pool for Senior CitizenRenewability / PortabilityCompulsory Health Benefits for organized sectorGovernment role on mass healthcare initiatives


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Constraints In Extending

Coverage75% of the population works in theinformal sector25% of the population below povertyline70% of the population in rural areas

Under insured countryHealth insurance an ill understoodsubject


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PolicyHolders

InsuranceCompany

T ird Partydministrator

HE LTHC REPROVIDER

Cashless Treatment

FRUSTRATIONS IN THE

SECTOR


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COST DRIVERS IN HEALTH

INSURANCET echnology / SpecializationPrescription DrugsMedical InflationMoral Hazard / Adverse SelectionNew treatments

Unnecessary treatments


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PROBLEMS FROM INSURERSPolicy condition problemsCustomer IgnorancePre-Existing Condition IssuesDisputes with hospitals / insured

Delays


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PROBLEMS FROM TPAsLack of Infrastructure

T here are no holidays in Health care yet offices not open on holidays, telephoneaccess unavailable, etcNo qualified doctor / staff

Delay in claim-settlement Deduction in bills without basisIncreased paperwork


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SOLUTION :Insurer

Designing a less complex products

Clarity in policy terms, conditions & exclusionsEfficient system for claims processingNeed for quicker services. E.g.: T oll free no's,cashless, quick responseExpense analysis on a regular basisProduct innovationEfficient training of sales force


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SOLUTION :Policy h older

Pay attention to policy conditionsRead the exclusions and limitationsvery carefullyCompare premium costs, deductibles,co-paymentsT ake an informed decision


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SOLUTION :

Th ird party administration

Proper infrastructureSpeedy claim settlement processLess paper workEfficient staff.


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Recent Initiatives Of IRDA

Committee to formulate regulationsPure health insurance products

Allowing the formation of an stand alonehealth insurance company

Renewability/policy renovation

Senior citizensData management/data poolT hird party administrators.


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Recent Concepts in H.IDay care surgeries/

treatment coveredinsurance.Co-payment concept

Health insurance throughcredit card.Micro insurance.


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Ch allenges in Healt h Insurance

Medical advance, both a challenge & alsoimpediment

Increase in health care cost Ageing population Acute shortage of trained personnel rangingfrom doctors to health care administratorsNew emergence and resurgence of olddiseases


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CONCLUSIONCreating awareness & meeting thedemand for health care & financingCreating modules for aligning theservices of all concernedFocusing on enhancing affordability &

reducing costsRapid coverage and health benefit to all


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W ANT TO KNO W MORE???www.healthinsuranceindia.orgwww.expresshealthcare.inwww.google.comBussiness world


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Thank You

While buying health insurance one isalso buying peace of mind, when one may need hospitalization

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Health+Insurance+n+TPA