Student Dissertation

Agency : Health Insurance, Claim Processing, Third Party Administrator, TPA Process

Objective : The study was undertaken with the overall objective of understanding the functioning of the TPA firm as a whole and to monitor the processes carried out on daily basis, to find out the attention seeking area where results are poor and to recommend & implement suggestions to improve TPA process which are responsible for causing delay.

Background : Third Party Administrator (TPA) is an organization which processes claims and provides cashless facilities as a separate entity. An insurance company hires TPA to manage its claims processing.TPA industry is a service field where customer satisfaction is the priority so the services rendered should be quick and of quality. The study is about the evaluation of multiple processes for betterment of customer services in TPA and an attempt to find the root causes for the problems and making the process more efficient by lowering the delay and decrease the rejection of claims and pre authorization forms.

Findings : The findings in this report focus on the monitoring of the delays in claim settlement. The report presents the findings in three sections a) Reasons for delay in full and final settlement of the claims. b) To find out the key reasons for repudiation of claims which is a disappointing factor for the patients as well as customers. c) To find out the reasons for denial of pre authorization forms. The average number of days taken by the organization to settle the file was 31 days which should be 8 days as per the insurance norms. The repudiation was also at a higher end. Mostly repudiation is due to non-coverage of the disease for which patient claims and because of pending documents.

Recommendations : The important components like settlement of claims and repudiation of claims where implementation of new strategy is very important and good pace needed. We cannot think of good 85 implementation without good and complete knowledge. So we need to train the workers as well as implement technologies in order to deliver good results. As per the study no processes were error free and smooth. With current status of processes and Turnaround Time of claim files it can be concluded that a lot of improvement is required in terms of training and technology for the betterment of services.


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