The document discusses a case study conducted at Apollo Hospital in Ahmedabad on the Third Party Administrator (TPA) process. It aims to understand the admission and discharge processes for TPA patients and identify reasons for delays. The study found that discharging a TPA patient takes 4-6 hours on average. Key causes of delay included incomplete discharge summaries, billing issues, consultant availability, and delayed approvals from the TPA. Recommendations to address the delays included improving pre-authorization forms, planning admissions and discharges, adding more staff to the TPA desk, and educating patients on the TPA process.

1. CASE STUDY ON TPA IN APOLLO
HOSPITAL, AHMEDABAD
9/11/2022
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2. WHAT IS TPA?
 The concept of TPA or Third Party Administrator has been
introduced by IRDA(Insurance Regulation and Development
Authority) for the benefit of both the insured and the insurer.
 TPA is intermediary between the Insurance Company and the
Insured and is responsible for issues including claim
settlement and authorizing cashless hospitalization.
 Provide services like:
 1. ID Card
2. Under-take “Pre-authorisation
3. 24 hours customer support services.
4. Cashless Hospitalization
5. Claim Management
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3. OBJECTIVE OF STUDY
Aim of the study:
 TPA desk in Apollo hospital looks after admission and
discharge of insurance patients, but time required for
this process is much larger. So this study is conducted
to understand process and reasons for delay.
Objectives of Study:
 To study the process of admission of TPA patients in the
hospital.
 To study the process of discharge of TPA patients in the
hospital.
 To identify the issues concerns with TPA management in
the hospital.
 To study the trends of TPA patients in Apollo hospital.
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4. METHODOLOGY
 Observation of the admission and discharge processes at TPA
desk.
 Carrying out a time motion study of the patient flow through the
system and documenting the time consumed for various sub
processes.
 Understanding the qualitative aspects of the processes through
unstructured interviews of the employees
Sources of Data Collection:
Primary Sources:
 Study of patient flow through admission and discharge process
 Unstructured interviews of staff
 Observation
Secondary Sources:
 Number of cases observed (sample size) – 25 TPA patients [30
form deluxe ward, 10 from standard ward and 20 form private and
semiprivate wards].
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5. TPA CHECK LIST
TPA check list:
 Documents required for cashless process are as
follows-
 TPA identity card (cashless card)
 Photo identity (driving licence/ pan card/ election card
etc.)
 Current year insurance policy document + last two
year’s policy documents
 Doctors consultation report
 Investigation report prior to admission
 Previous hospitalization reports (discharge summary,
investigation reports)
 For cashless process preauthorization should be
submitted within 24 hours of admission
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6. TPA EMPANELLED WITH HOSPITAL
 Anmol
 Apollo DKV
 AXA Healthcare
 Bajaj Allianz
 Cholamandalam MS
 Dedicated Healthcare
 E-Meditek Services Ltd
 Family Health Plan Limited
 Future Generali
 Health India
 HERITAGE
 ICICI LOMBARD
 ICICI Prudential
 Iffco Tokyo
 Safeway
 Star well
 TTK health
 Vipul Medco
 Max Bupa
 MD India
 Medi Assist India Pvt.
 Medicare
 Medisave
 Paramount
 Parekh/United Healthcare
 Raksha
 Reliance general insurance
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7. TPA DATA FOR THE MONTH OF FEB 2012
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0
50
100
150
200
250
No. Of Cases in Month
No. Of
Cases in
Month

8. TPA PROCESS FLOW
Patient approaches Hospital
Hospital faxes/e-mail
preauthorization form to TPA It
contains: 1. TPA card copy /
policy copy of last 3 years.
2. ID proof
3. Indoor advice case paper
4. Retrieval Diagnostic reports
Request received by TPA, TPA
check for cost estimate, policy
term and conditions for eligibility
Claim approved (subject to policy
condition and estimated cost) by
TPA
Response (Authorization letter) is
faxed/ emailed to hospital
At the time of discharge Hospital
submits Discharge summary and
final bill to TPA, TPA processes
the claim on the basis of eligibility
and actual cost
TPA gives approval for patients
bill
Patient gets discharged from
hospital and settles difference
amount if any
TPA makes the claim payment to
the hospital (as per the policy
terms and actual cost)
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9. ADMISSION PROCESS FOR TPA PATIENTS
 Insurance patients after coming to hospital first visit
consultant in OPD/ Emergency
 If consultant advice admission then they are directed
towards TPA desk
 At TPA desk patients insurance policy is checked for
continuity and TPA associated with policy
 TPA preauthorisation form and TPA consent form is
given to patient for filling. Preauthorisation form is filled
by consultant and signed. This form along with policy
document and photo ID copy of patient is mailed / faxed
to TPA for approval.
 Patient is admitted in respective ward, preauthorisation
comes within 24 hrs of admission same is
communicated with patient.
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10. DISCHARGE PROCESS FOR TPA PATIENT
 Consultant says patient can be discharged during daily visit to patient in
ward
 Nursing staff informs Medical officer, ward secretary, and pharmacist about
patient discharge
 Medical officer writes discharge summary of patient and gives to typist for
computer typing, After consultant finals summary one copy is sent to TPA
desk for claim settlement.
 Ward secretary completes patient file, arranges reports in grey folder,
 Pharmacist returns patients remaining medicines and indents discharge
medicines and makes IP OK sign on billing card
 Ward secretary sends that billing card to the billing department for final
billing of patient
 Inpatient billing departments gets clearance from all departments and
prepares final bill for that patient, one copy is sent to the TPA desk.
 TPA desk sends that final bill and discharge summary to TPA company for
final approval of bill. It takes minimum 1 hour for bill approval from TPA
Company.
 After final approval is received from TPA, one copy of that approval letter is
submitted in billing department then bill settlement is done
 Patient goes in ward collects his documents and leaves hospital.
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11. TAT OF TPA PATIENT
Time and motion study of TPA Discharges:
 25 TPA discharges studied for identifying time
required for discharges and factors causing delay in
discharge of patient.
 It takes around 4-6 hours for TPA patient to get
discharge from hospital. The delays can be
grouped in two categories—1) Delay happening
from hospital side (i.e. delay in discharge summary,
delay in billing etc.) and 2) Delay happening from
TPA side (i.e. delay in getting approval from TPA).
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12. CAUSES FOR THE DELAY
0
2
4
6
8
10
12
14
16
No. of Cases
Discharge summary not ready
Billing not ready
Consultant was busy
TPA delayed approval
System crashed
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13. ISSUES AND CHALLENGES
 Discharge of insurance patient is not conveyed to
TPA desk from ward
 The insurance desk has staff problem, staff working
on insurance desk is very low
 Location of TPA Desk
 Mistakes in Discharge summaries
 Network problem
 Improper communication
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14. RECOMMENDATIONS
 The pre-authorisation forms should be available on
the computer of all the doctors.
 Consultants should make planned admission for
insurance patients
 All insurance patients should be in planed
discharges
 More staff should be appointed at TPA desk
 It is very important for the TPA patient to be told
about the entire process
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15. 9/11/2022
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