Third-party Administrators Research Articles

Technology And Innovation In HR

In India, the high cost of medical education, particularly for an MBBS degree, poses significant challenges for new doctors, who often find that their qualifications do not justify the Expenses incurred. This financial strain is exacerbated when these highly trained professionals are employed for routine tasks such as insurance treatment and billing verification, roles that are not commercially viable given their level of education and potential. As a cost-effective measure, many insurance companies and third-party administrators (TPAs) opt to employ doctors with BHMS or BMS degrees for these tasks. However, these professionals are often underqualified for the complexities of medical verification, leading to inefficiencies and errors in treatment validation and anomaly detection. The situation also adversely affects programs like the Ex-Servicemen Contributory Health Scheme (ECHS), where the need for accurate and efficient cashless medical services is critical. Delays and inaccuracies in medical verification can complicate the provision of timely healthcare to veterans and their families, underscoring the need for improvement in these processes. This paper proposes the implementation of an Artificial Intelligence (AI) ecosystem designed to function as highly qualified medical agents. This AI system will be capable of independently verifying diagnoses, treatment plans, and medical reports for accuracy while also identifying procedural anomalies. The primary objective is to augment the capabilities of the current workforce, enhancing overall efficiency and effectiveness in medical management. By deploying AI medical agents, the project aims to not only address the gap in qualification and task complexity but also improve the accuracy and reliability of medical administrative processes. This initiative promises to revolutionize the way medical verifications are handled, providing a sustainable, scalable solution to a pressing healthcare management issue in India.

Comparative Assessment of External Third Party Administrators and In-house Teams of Insurers in Health Insurance Claims Settlement Process in Bangalore, India

Claim servicing in health insurance is an important area for insurers. Third party administrators (TPAs) are a critical link in India that process health insurance claims. Several insurers have started in-house claim teams for health insurance claims instead of outsourcing the work to TPAs. The study aims to explore the role played by external TPAs in terms of value addition done by them for insurers, policyholders and healthcare providers. The study aims to find the benefits of roping in an in-house team to settle health claims and the benefits accruing out of this decision to policyholders and hospitals. The role of TPAs in claim processing, issues faced by customers while making a claim, and improvement areas in the process have also been examined. The author has tried to explore and research this area so that policyholders can choose a health insurance company without bias whether it has an in-house claim settlement process or engages an external TPA. The study brings out the concerns of customers and hospitals regarding the settlement of health insurance claims and suggests improvement areas required for both TPAs and in-house teams in claim settlements by evaluating the same.

Who Should Address Third-Party Administrators?

Who Should Address Third-Party Administrators?

Prevalence and nature of manufacturer-sponsored patient support programs for prescription drugs in Canada: a cross-sectional study.

Globally, pharmaceutical companies offer patient support programs in tandem with their products, which aim to enhance medication adherence and patient experience through education, training, support and financial assistance. We sought to identify the proportion and characteristics of such patient support programs in Canada and to describe the nature of supports provided. We conducted a crosssectional study to identify and characterize all marketed prescription drugs available in Canada as of Aug. 23, 2022, using the Health Canada Drug Product and CompuScript databases. To describe the nature of supports provided, we conducted a content analysis of publicly available patient support program websites and Web-based documents. Using logistic regression, we identified characteristics of drugs associated with having a patient support program including brand-name or branded generic (generic medications with a proprietary name), orphan (medications for rare diseases) or biologic drug status; estimated total cost of prescriptions dispensed at retail pharmacies; and price per unit. Of the 2556 prescription drugs marketed by 89 companies in the study period, 256 (10.0%) had a patient support program in Canada. Many of the 89 drug manufacturers (n = 55, 61.8%) offered at least 1 patient support program, frequently relying on third-party administrators for delivery. Brandname and branded generic medications, biologic agents and drugs with orphan status were more likely to have a patient support program than generic drugs. Compared with drugs priced $1.01-$10.00 per unit, drugs priced $10.01-$100.00 per unit were nearly 8 times more likely to have a patient support program (adjusted odds ratio 7.54, 95% confidence interval 4.07- 14.64). Most sampled patient support programs included reimbursement navigation (n = 231, 90.2%) and clinical case management (n = 223, 87.1%). About 1 in 10 drugs marketed in Canada has a manufacturersponsored patient support program, but these are concentrated around brand-name, branded generic, biologic and high-cost drugs, often for rare diseases. To understand the impact of patient support programs on health outcomes and sustainable access to cost-effective medicines, greater transparency and independent evaluation of patient support programs is necessary.

Growing administrative complexity in the 340B program and the rise of third-party administrators.

The 1992 340B drug discount program lowers drug costs and provides a source of revenue for safety-net providers by entitling them to discounts on drugs for all patients, including those with insurance. As 340B has grown so has the administrative complexity of the program, creating a market for third-party administrators (TPAs) to manage both formal and informal requirements in exchange for fees. Although TPAs are playing an important role in the 340B ecosystem, the TPA market is poorly understood, along several dimensions including its size, specialization, competitiveness, and scope of services offered. In this brief report, we report the results of original market research on TPA firms to address unanswered questions and identify gaps in knowledge. We identify 48 TPA firms, including 8 owned by private equity firms, 2 owned by software companies, and 6 owned by a variety of vertically integrated health care stakeholders such as pharmacies, pharmaceutical benefit managers, and pharmaceutical wholesalers. We identified 7 services offered by TPAs including patient discount cards (13), enrollment (31), auditing (45), revenue capture (42), referral management (9), inventory management (19), and 340B ESP assistance (9). Our results suggest that TPAs are involved in many diverse functions related to 340B.

Veteran Behavioral Health Care in the VHA and Elsewhere.

Veteran Behavioral Health Care in the VHA and Elsewhere.

Impact of claim settlement procedure of health insurance companies on customer satisfaction during the pandemic: A case of third-party administrators

The claim settlement process is one of the most critical aspects of health insurance. Many policyholder grievances often surface during claim settlement, which will likely shape the insurer’s reputation. Hence, this study aims to evaluate the relationships between hypothesized factors concerning the third-party administrator’s claim settlement process as perceived by policyholders. The paper used the data of policyholders from Delhi/NCR, India, who have availed the cashless claims in the last three years. In the process, a total of 790 questionnaires were sought to be. The methodology used was the extractive factor analysis comprising the KMO test, reliability assessment with Cronbach’s Alpha, and correlation assessment. The study attempted to evaluate all the contributing factors that shape the third-party administrator’s behavior during the claim settlement. Therefore, different factors were identified (themes A, B, C, and D). The study reported a significant relationship between insurance company perceptions (0.162), network hospital perceptions (0.182), product design (0.180), insurance agent (0.332), communications (0.114), disclosure (0.122), internal practices (0.143), and TPA claim settlement prospects across the Indian perspective. The contextual impacts on individual and group decision-making must be monitored and accommodated across effective public policy management concerning settlement of health insurance claims. The study findings could help insurers create business models leading to better customer satisfaction and congruence between agents, policyholders, TPAs, and health insurance companies.

Performance of Third Party Administrators in Indian Healthcare

Health insurance companies, healthcare service providers and third party administrators (TPAs) play an important role in health system performance. Our study develops performance metrics for TPAs in the Indian healthcare setting. Further, we examine the relative importance of these metrics among the market segments that TPAs service. Auditing of TPAs on performance measures is not prevalent practice in the industry. This evaluation will enable critical assessment of both efficiency and quality of health insurance claims processing and provide insights on required modifications thus resulting in better performance and enhanced customer satisfaction. This study’s motivation stems from the possible impact that the objective performance evaluation of TPAs has on healthcare delivery, control and costs. Analytical Hierarchy Process was used to formulate a hierarchy of factors to determine TPA performance and to assess their relative importance among the market segments serviced. The findings suggest that the relative importance of performance metrics for TPAs vary across market segments. This study is limited to TPA performance. Studies can be undertaken to understand the performance metrics of other members in the healthcare system, such as clinics, hospitals and insured members.

General practitioners’ views on retaining Singapore’s primary care doctors: a cross-sectional survey and qualitative analysis

BackgroundTo support its ageing population and the increasing need for chronic care in the community, Singapore needs to boost the number of doctors in its primary care workforce. To better understand how to improve doctor retention and build a more robust primary care system, we conducted a cross-sectional survey with doctors in general practice and family medicine to explore their career satisfaction, their career plans, factors related to their plans to leave, and their view on retaining GPs in primary care.MethodsAn anonymous online survey was distributed to general practitioners working in the public and private sectors. The survey contained questions on career satisfaction, career plans in the next 5 years, and factors important for retaining doctors in primary care. In addition, there were open-ended questions for respondents to elaborate on retention initiatives and other factors that may improve engagement among primary care doctors. Quantitative data was analyzed with descriptive statistics, principal component analysis, χ2 tests, t-tests, and Pearson’s correlations; qualitative data was analyzed thematically.ResultsThe survey was attempted by 355 general practitioners and completed in full by 303. The respondents were most satisfied with rapport with patients and their current professional role; they were least satisfied with the amount of paperwork and the status of general practice in society. In terms of their career plans in the next 5 years, 49/341 (14.4%) of the respondents plan to leave general practice permanently, 43/341 (12.6%) plan to take a career break, and 175/341 (51.3%) plan to reduce their clinical hours. Higher remuneration, recognizing general practice and family medicine as a medical specialty, and reducing the litigious pressures on medical practice were rated as the most important factors for retaining primary care. Free-text responses also revealed a growing dissatisfaction with the Third-Party Administrators that manage insurance arrangements.ConclusionWhile the proportion of doctors who intend to leave is smaller than that reported in overseas studies, our findings highlight an urgent need for targeted interventions to engage and retain primary care doctors. Increasing recognition and support for general practitioners and their professional practice may contribute to strengthening community care for the ageing population.

Veteran Perspectives on Care Coordination Between Veterans Affairs and Community Providers: A Qualitative Analysis.

To investigate veteran perspectives on challenges in care coordination between US Department of Veterans Affairs (VA) clinics and community providers in rural areas. We completed qualitative interviews with a geographically diverse sample of 51 veterans who had used both VA and community health care services. Interviews were audio-recorded and transcribed verbatim. We used directed content analysis (informed by previous work with VA and community staff) to elucidate findings, while remaining attentive to emergent themes. We report results in 5 key domains related to interorganizational care coordination: organizational mechanisms, organizational culture, relational practices, contextual factors, and the role of the Third-Party Administrators responsible for scheduling and payment for community services. Veterans described successes and challenges in interorganizational coordination across these domains, while also reporting a variety of workarounds and mitigation strategies. Veterans living in rural areas face myriad challenges when using health care services both within and outside of VA. In the absence of strong mechanisms for ensuring coordination and communication between health care providers at different institutions, veterans themselves may carry the primary burden for coordinating their care. Our results suggest the utility of both structural and relational approaches to enhancing interorganizational care coordination in these settings.

Growth and Performance of General Insurance Companies in India – Premium Rate and Claim Settlement Perspective

Life is full of risks and uncertainties. In fact risk is everywhere. Even when you ride a bike to the nearest shop in the street, there is a risk. One must protect himself or herself from this risk. The solution is insurance. Broadly it is two types i.e. life insurance and non-life insurance (general insurance). In this paper we discuss about only general insurance. General insurance helps in securing ourselves and things we value like homes, cars, bikes or any other property from any kind of mishap whether it is big or small. General insurance protect insured property from fire accidents, floods, earthquakes, storms, thefts, travel accidents/mishaps or any other kind of calamity, even from the cost incurred against us from legal action depending upon the type of policy selected by the insurer. From the post liberalization scenario, general insurance in India is growing rapidly. The reasons behind its spectacular growth are allowing private companies to enter into Indian market, low insurance premium, TPAs (Third Party Administrators), Fast and immediate settlement of insurance claims, Innovative general insurance policies, discounts in insurance products, increasing awareness among people, more distribution channels etc. The other side of the coin is, public sector insurance companies are facing cut throat completion from private insurance companies as they offer wide variety of policies at a low premium. Due to this few general insurance companies are closed and few are forced to come out with same polices and services. Ultimately the performance of public sector general insurance companies also enhanced with the competitive moves by private players. On the other hand, customers are also exposed to new trends in the insurance market. Insurance Regulatory and Development Authority (IRDA) is the apex body in India to monitor the activities of insurance companies. It has laid down standard terms and conditions to general insurance companies and also given scope for personal accidental life insurance policies. IRDA has taken all the measures to improve the performance of general insurance companies as it is one of the fast growing areas in Indian economy.

The Dynamics of General Insurance Sector in India Growth and Performance Perspective

Life is full of risks and uncertainties. In fact risk is everywhere. Even when you ride a bike to the nearest shop in the street, there is a risk. One must protect himself or herself from this risk. The solution is insurance. Broadly it is two types i.e. life insurance and non-life insurance (general insurance). In this paper we discuss about only general insurance. General insurance helps in securing ourselves and things we value like homes, cars, bikes or any other property from any kind of mishap whether it is big or small. General insurance protect insured property from fire accidents, floods, earthquakes, storms, thefts, travel accidents/mishaps or any other kind of calamity, even from the cost incurred against us from legal action depending upon the type of policy selected by the insurer. From the post liberalization scenario, general insurance in India is growing rapidly. The reasons behind its spectacular growth are allowing private companies to enter into Indian market, low insurance premium, TPAs (Third Party Administrators), Fast and immediate settlement of insurance claims, Innovative general insurance policies, discounts in insurance products, increasing awareness among people, more distribution channels etc. The other side of the coin is, public sector insurance companies are facing cut throat completion from private insurance companies as they offer wide variety of policies at a low premium. Due to this few general insurance companies are closed and few are forced to come out with same polices and services. Ultimately the performance of public sector general insurance companies also enhanced with the competitive moves by private players. On the other hand, customers are also exposed to new trends in the insurance market. Insurance Regulatory and Development Authority (IRDA) is the apex body in India to monitor the activities of insurance companies. It has laid down standard terms and conditions to general insurance companies and also given scope for personal accidental life insurance policies. IRDA has taken all the measures to improve the performance of general insurance companies as it is one of the fast growing areas in Indian economy. General insurance companies under public sector are facing lot of challenges from private players and to with stand in the completion, even they have improved a lot in their quality of service in multiple facets like decreasing the premium, quick settlement in claims etc. In a nut shell, general insurance business is contributing significantly to Gross Domestic Product (GDP).

Operational Efficiency of Selected General Insurance Companies in India

Life is full of risks and uncertainties. In fact risk is everywhere. Even when you ride a bike to the nearest shop in the street, there is a risk. One must protect himself or herself from this risk. The solution is insurance. Broadly it is two types i.e. life insurance and non-life insurance (general insurance). In this paper we discuss about only general insurance. General insurance helps in securing ourselves and things we value like homes, cars, bikes or any other property from any kind of mishap whether it is big or small. General insurance protect insured property from fire accidents, floods, earthquakes, storms, thefts, travel accidents/mishaps or any other kind of calamity, even from the cost incurred against us from legal action depending upon the type of policy selected by the insurer. From the post liberalization scenario, general insurance in India is growing rapidly. The reasons behind its spectacular growth are allowing private companies to enter into Indian market, low insurance premium, TPAs (Third Party Administrators), Fast and immediate settlement of insurance claims, Innovative general insurance policies, discounts in insurance products, increasing awareness among people, more distribution channels etc. The other side of the coin is, public sector insurance companies are facing cut throat completion from private insurance companies as they offer wide variety of policies at a low premium. Due to this few general insurance companies are closed and few are forced to come out with same polices and services. Ultimately the performance of public sector general insurance companies also enhanced with the competitive moves by private players. On the other hand, customers are also exposed to new trends in the insurance market. Insurance Regulatory and Development Authority (IRDA) is the apex body in India to monitor the activities of insurance companies. It has laid down standard terms and conditions to general insurance companies and also given scope for personal accidental life insurance policies. IRDA has taken all the measures to improve the performance of general insurance companies as it is one of the fast growing areas in Indian economy.

Often Posed Questions (and Answers) Regarding Medicare, Contracting, and Non-Hearing Aid Services.

Medicare Part B provider participation is often met with grumbling and disdain by most health care providers, including audiologists. Other pain points for audiologists likely include insurance contracts, third-party administrators, and the unknown of the future. The dynamic landscape that will include technology and delivery systems was, until recently, mere thoughts on paper and in conference rooms. With the moderate amount of misunderstanding about Medicare and contracting rules among the members of the profession, it is this article's intent to dispel these Medicare myths as they pertain to hearing and balance services provided by Medicare Part B-enrolled audiologists, to offer considerations in a practice's decision whether to accept commercial insurance and third-party payer contracts, and to offer the tools to position a practice to provide non-hearing aid-related services based on today's current information.

Network Adequacy, Reimbursement Key to Expanding Access, Panel Agrees

Businesses are well positioned to ask health plans for data to improve accountability—they are paying for benefits but are not getting what they paid for when employees cannot access behavioral health care.

Accessing Care Through the Veterans Choice Program: The Veteran Experience.

The Veterans Choice Program (VCP) was implemented to improve healthcare access by expanding healthcare options for Veterans Health Administration (VHA) enrollees. To understand Veterans' experience accessing VCP care. Qualitative content analysis. Forty-seven veterans from three medical centers in three of the five VA geographical regions. We used semi-structured telephone interviews designed to elicit descriptions of Veterans' experiences. Data was analyzed using iterative, inductive, and deductive content analysis. Broad themes were identified based on representative interview responses. We identified six themes: general impressions (concept and frustration); preferred source of care (institution, specialty, and individual provider); facilitators (VA staff facilitation and proactive Veterans); barriers (complexity, lack of responsiveness, lack of local providers, and poor coordination); perceived sources of VCP problems (learning curve, leadership and staff, and politics); and unintended negative impact (responsibility for costs of care and discontinued access to community care). Most Veterans who had received care through the VCP felt that it improved their access to care. However, accessing care through the VCP is a complex process that requires proactive Veterans and active support from the VA, third-party administrators, and availability of participating community providers. Veterans' abilities to navigate this process and the level of support provided varied widely. Even patients who did receive care through VCP found the process challenging. Greater support is needed for some Veterans to successfully access VCP care because Veterans who need care the most may be the least able to access it.

Changing Preferences, Moving Places and Third Party Administrators: A Scoping Review of Medical Tourism Trends (1990-2016)

An overview is given of latest trends in medical tourism and its conceptualization with an industry analysis. The rapidly evolving health awareness and preferences of medical tourists, in tandem with medical treatments’ higher levels of affordability across the globe, have changed the global medical tourism industry sharply in recent decades, and many international health systems are being opened to patients’ greater cross-border movements. A scoping literature review (1990-2016) depicts the recent boom in medical tourism as presenting certain opportunities, and uncovers many challenges which are involved in its policymaking. These developments denote greater mobility of places (P) for medical treatments, affordability (A) levels to bear the inflated treatment costs (C), changing preferences of medical tourists with the passage of time (T) and participation of third party administrators (TPAs) in their overall operations. The study espouses a rise in medical tourism from the United States (US), and participating countries in Europe, Asia and Africa with participating countries, identifies a need for profound policymaking, and highlights the importance and applicability of TPC-TPAs link chain in medical tourism context. This study further recommends understanding the role of industry stakeholders, particularly governments, in the policymaking of medical tourism in order to steer the industry appropriately.

Demystifying Insurance Regulatory Changes Relating to Commercial Health Insurance in India

The health insurance, among other available alternatives, is very effective tool to provide financial support in respect of expenditures arising from medical care and treatment by availing cashless treatment or expenditure reimbursement to the person who contributes to the insurance company in form of premium. The system of health insurance includes the health insurance companies, the policyholders, Third Party Administrators (TPAs) and network providers which have been assigned distinct statutory roles to be played for smooth conduct and proper development of health insurance business. In this respect, taking into account the developments taken place in insurance industry as well as recommendations and representations of various entities, the Insurance Regulatory and Development Authority of India (IRDA), the regulator of Indian insurance industry, has recently made Regulations and Guidelines incorporating some new provisions having the overarching effects. This paper attempts to demystify the recent regulatory changes relating to health insurance in India.

Brief Amici Curiae of Transgender Legal Defense and Education Fund, World Professional Association for Transgender Health, and Whitman Walker Health in Support of Appellant Urging Reversal

This amici curiae brief filed on behalf of the Transgender Legal Defense and Education Fund, World Professional Association for Transgender Health, and Whitman Walker Health in Tovar v. Essentia Health et al., 857 F.3d 771 (8th Cir. 2017), shines a light on why transgender healthcare exclusions are discriminatory and explains why third-party administrators of employer provided health plans are liable for discriminatory healthcare exclusions. The Eighth Circuit ultimately adopted views espoused in the brief.

Service diversification and service quality differences in the third-party administration of US organic regulations

ABSTRACTThis paper makes the case that ‘competitive third-party regulatory arrangements’ draw attention to the service provision aspect of regulatory administration. Using multiple methods, the study examines service diversification and service quality differences exhibited by third-party administrators of US organic food regulations. By examining how the service emphases of third-party regulatory administrators differ by organizational form, the study documents that the inclusion of nonprofit and private third-party regulatory administrators may expand the services that are offered and performed alongside regulatory program functions. The implications of the findings for regulatory administration, and the field of public management generally, are discussed.