TPAs Are Crucial To Safeguard Insurance Companies Against Fraud Satish Gidugu

In an interaction with BW Healthcare World Mr Satish Gidugu, CEO and Whole Time Director, Medi Assist, speaks on how digitisation transformed health insurance claims, role played by Third Party Administrators (TPAs) in pandemic, intervention by TPAs ​​to reduce fraudulent claims, impact of 5 per cent GST on room rents on policyholders, and technological interventions that will improve the claims process

How has Digitisation transformed the business of health insurance claims?

The emergence of new technology trends in the past few years have affected every industry. Technological advancements and Digitisation are critical to unlock and deliver new value in the insurance sector. TPAs ​​(Third Party Administrators) such as Medi Assist, which is essential to running the insurance ecosystem, have adapted to technologies like AI and ML to aid in reshaping product designs, claims procedures, underwriting, and distribution, resulting in a greater connection with clients. It all comes down to easing insurance usage for end users and opening up new pathways and opportunities for insurance companies to offer new and innovative products.

What role did TPAs ​​play in claims settlement during the pandemic? Did the regulatory body provide any special guidelines?

The pandemic saw the onslaught of claims and confusion. TPAs ​​proactively engaged with Insurers/corporates to facilitate faster processing and settlement of claims for the insured. For example, TPAs ​​made sure that claims were processed/settled via scanned copies to avoid delay/non- submission of physical documents. Robust BCP was in place for smooth and continuous service though the majority of the employees were working remotely

The IRDAI issued various guidelines advising insurers to cover Covid 19 claims. They also advised insurers to issue short-duration covid-specific policies and consider cashless claims/RI claims from makeshift hospitals.

How has the intervention by TPA impacted the filing of fraudulent claims?

TPAs play a critical part in safeguarding insurance companies against fraud. During the pandemic, TPAs ​​continuously monitor covid claims through tele-calling/desktop verification followed by Physical verification, wherever necessary, to protect insurers against fabricated claims. TPAs ​​also saw through patterns/trends of claims and identified possible frauds to safeguard insurers’ interests.

How will policyholders be impacted by the recent GST council’s decision to levy 5 per cent GST on hospital bed rentals over Rs.5000/- per night?

Many insurers have confirmed that GST is admissible as a part of room rent eligibility. The overall impact on the claims will be minimal, considering many large corporations and Policies with high sum insured (>5 lakhs) may have only a single AC room as eligible , and hence GST will get paid (subject to availability of the sum assured).

What is the scope of technological interventions that could improve overall coherence in the claims process?

Technological interventions are impacting the insurance ecosystem–across processes and functions. The process key to the entire functioning of the sector–claim processes–has seen massive overhauling.

At Medi Assist, we’ve upgraded our self-serving digital capabilities and digitised our underwriting and risk assessment processes. In FY-22, over 81 per cent of cashless claims were submitted online. Furthermore, the advanced technology enables members to preauthorize cashless hospitalisation approvals in under 45 minutes on average. More than 20 per cent of our claim volume is processed through the automated channel with fewer than 10 minutes of processing time.

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