Student Dissertation

Agency : Health Insurance; Third Party Administration; TAP Procedure; Claim Settlement; Root Cause Analysis

Objective : • To understand the system of TPA procedure • To find out main problem behind the denial in claim settlement • To carry out root cause analysis • To suggest key strategies to overcome the denial rate

Background : The health infrastructure in India is facing daunting challenge of meeting the health goals and complexities emerging from the changing disease pattern. Need of health insurance is on a rise these days owing to intimidating reasons like souring numbers of communicable and non- communicable diseases, changing disease pattern, low public spending on health care, high out of pocket expenses, poor public health care setup, advent of corporate hospitals, costly line of treatment in private hospital due to highly paid qualified doctors and other challenges of health goals. Health insurance is emerging fast as an important mechanism to finance health care needs of people. The term ‘Health Insurance’ relates to a type of insurance that essentially covers your medical expenses. A health insurance policy like other policies is a contract between an insurer and an individual / group in which the insurer agrees to provide specified health insurance cover at a particular “premium” subject to terms and conditions specified in the policy. A health insurance policy is a contract between an insurance company and an individual or his sponsor (e.g. an employer). The contract can be renewed annually or monthly. The type and amount of health care costs that will be covered by the health insurance company are specified in advance. The Third-Party Administrators were licensed by Insurance Regulatory and Development Authority to regulate the health care costs and improvement in services in hospitals to benefit the society as a whole.

Methodology : • Study type: Descriptive study to analyze denial rate of TPA department • Study area: Sarvodaya Hospital and Research Center, Faridabad • Study population: In-patients & day care patients of Sarvodaya hospital • Sample size: Mediclaim patients admitted in Sarvodaya hospital • Study time period: 3 Months • Sources of data: Data was collected on day to day basis and recorded in excel sheets. • Primary data: direct observation • Secondary data: from his and REMEDINET online portal • Methods of data collection: Direct observation REMEDINET online portal and his

Findings : According to the study done, TPA patient in month of March and April are 38%and 40% respectively out all the patients admitted in the hospital in same time-period. Majorly three types of TPA patients admit in the hospital and they are: Dialysis patient, elective cases, patients for Conservative Management. Out of these three types of discharges, Maximum denials occur for patients admitted for conservative management i.e. 71%. On analyzing reasons for denials, Major reason which is found is Policy Clause. Other Reasons include waiting period, Medical Reasons, Pre- Existing disase, Hospitalization not justified etc.

Recommendations : The introduction of TPAs was made by IRDA in order to infuse a new management system and to regulate the health care services and costs. The prologue of Third Party Administrators was made on the expectation to ensure better services to insurers as well as to insured. The prologue of Third Party Administrators was made on the expectation to ensure better services to insurers as well as to insured. Denials not only cause loss in revenue but also a major contributing factor in Patient Dissatisfaction.


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