The tussle between healthcare providers and insurance companies has drastically reduced the number of cashless claims in the city.
While third party administrators (TPAs) used to process about 200 cashless applications per day, the number has reduced to 10-15 applications since last week.
“When a patient wants to avail of cashless benefit, he has to get in touch with the TPAs, who process authorisation letters suggesting that the policy-holder will get a sanction of the required amount,” a senior executive from a TPA said, adding that they earlier sent 150-200 authorisation letters daily.
“However, the number has dropped to 10-15 applications per day,” he said, adding that it was similar with TPAs across the city.
TPAs are involved in processing insurance claims on behalf of government-owned insurance companies.
According to insurance companies, they had to introduce the preferred provider network programme as the claim ratios had gone up drastically due to inflated bills from hospitals and having TPAs as middle parties. Experts feel that multiple factors are responsible for increased claim ratios.
“Factors like inappropriate increase in per capita premium and improper assessment of medical history by the insurance provider are also responsible for increased claim ratios,” said Nayan Shah, managing director, Paramount TPA.
According to Shah, many insurance companies offer policies to people which cover existing ailments. Also, group insurance, which is 50% of the market, covers all ailments since the day the policy is taken. “These factors have played a vital role in increasing claims, which insurance companies may not have considered,” added Shah.
Insurance experts feel that many hospitals and doctors have taken advantage of the policies by admitting the patient even when not required, offering single accommodation rooms that are costly. “Such tactics are very common with hospitals and nursing homes,” an insurance consultant said.
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