TPA vs In-House Medicare Claims Process: The Differences You Need To Know


The process of settling health insurance claims is one of the most important aspects of a policy. You can have your health insurance claim settled by the insurer in two ways: an internal claims processing department and a TPA or third party administrator.

“When purchasing a policy, a buyer should understand that PTAs associated with insurers are available for processing health insurance claims only. They cannot accept or reject claims, the power of acceptance or rejection rests solely with the insurers. In addition, there is no APT for other types of insurance such as life insurance or auto insurance, ”said Ankit Agrawal, CEO and co-founder of InsuranceDekho.

A TPA acts as an intermediary between the insurer and the claimant, which facilitates the settlement / processing of health insurance claims. A TPA is appointed by the insurance company.

The internal complaints handling service, also known as the Health Administration Team (HAT), is set up by insurers within their own company.

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Both methods facilitate the claims settlement process and have advantages and disadvantages. In this article, we take a look at five major differences between them.

Better services than APTs

To set themselves apart from the competition, insurance companies offer unique facilities to policyholders. Creating an internal complaints process allows the insurance company to provide special offers, including ease of handling complaints, shorter turnaround time (TAT), etc. to insureds from time to time.

The process is smooth and faster than TPA

Since the policyholder can deal directly with the insurer via internal claims settlement, the processing of the claim takes less time than a TPA which acts as an intermediary between the insurer and the policyholder. .

“Sometimes a TPA can be incompetent to handle a group of cases and rely on the insurer to make a decision,” Agrawal said.

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TPAs depend on insurers

TPAs depend on insurers for the settlement of health claims, which is not the case in the internal claims settlement process because ultimately, it is the insurers who directly pay for the health claims. It can be another advantage to choose an internal complaints resolution process.

APTs have a larger hospital network

TPAs have their list of network hospitals, which is usually longer than that of any insurer’s in-house claims service. Hence, it can be said that the coverage extent of cashless treatment in hospitals in the APT network is higher than that of most insurance companies in India.

APTs Offer Better Claims Settlement Facilities

Agrawal said, “TPAs can provide better facilities for policyholders to make claims under their health insurance policies by making the process easily understandable. Whereas, in the case of in-house claims service, you have to go through the customer service route, which may take longer. “

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TBEN to go

The internal complaints department and the TPA provide efficient processes for resolving health insurance claims. While the differences mentioned may help you choose wisely between health insurance companies offering TPA or an in-house claims service, you shouldn’t make a policy purchase decision based on these factors alone. Instead, you should also consider other factors, such as the coverage benefits offered under the health policy, exclusions, insurers’ claims settlement rate, waiting time, etc. .

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