Third party administrative support (TPA)
THIRD PARTY ADMINISTRATIVE SUPPORT (TPA)
Savitar Group provides TPA (third party administrator) services for international health insurance companies or self-insured companies. TPA is a link between health insurance company, policyholder and healthcare provider. For international insurance companies that enter the Russian/CIS market TPA is a benefits-manager and cost-control provider as well as an essential tool to compete with local insurance providers.
Savitar Group provide the following services within TPA:
1. 24/7 call center. The call center is operated by multi-lingual staff. There are toll-free numbers in Russia and local phones in CIS countries. Call center is responsible for:
- Policy validation
- Check of coverage, limits, policy terms with the insurance company
- Organization of out-patient and in-patient treatment
2. Cashless access to our own network of medical providers. In this case the insured has cashless access to any medical facility that is more convenient and not only those that have cashless agreements with the insurance company. This is convenient for clients and an effective method to control costs because usually international insurance companies only have agreements with the most expensive international style clinics. They are not always the most convenient for clients and not always of the best quality but they are preferred by clients because they will have nothing to do with claim forms, medical reports and reimbursement.
3. Claim management. Due to quite complicated “state currency control” in Russia it is sometimes a challenge to arrange payment to a Russian tax resident from abroad. In every case there should be a bilingual agreement, original bills and a number of other procedures required by authorities. It doesn’t cause much trouble when it concerns long-term contract but it is a problem when it is necessary to pay to different medical providers and when it is necessary to reimburse a large number of individuals. The TPA claims-handling service allows you to deal only with one company.
- Placement of the letter of guarantee to the healthcare providers
- Collection of the document from healthcare providers
- Translation of the documents
- Payment to the medical provider
- Reimbursement to the patient on behalf of the insurance company.
4. Cost containment.
- Guaranteed discounts in the number of providers. Local TPA has discounts in clinics and access to the price-lists for local companies (many clinics have different prices for residents and expats, in some cases the difference is not in prices but in billing structure – in one case the “hospital day” may include nursing care, meals, wound dressing, and in another case it is only “hospital day” and everything extra is charged separately.
- Negotiation on the number of medical services provided to the patient. There are different international and local “medical protocols”. Russian healthcare providers do not follow unified protocols. Combination of different protocols can lead to over-treatment and over-billing.
- Fraud investigation. Although the overall situation has changed for better, Post-Soviet Union countries still remain a major and advantageous field for multiple half-legal medical organizations and fraudulent claims. Savitar Group team strives to perform the best possible way in dealing with the request for assessment of documents. Our core principles in fraud investigations are: always checking the legal status of a suspected fraudster – both legal and physical entities; applying both medical and financial assessment of invoices from medical facilities; using past history of relations with a suspected entity – if any available; studying of usual, most common behavioral tendencies of fraudsters; In case of any doubts – addressing independent specialists for an expert opinion.
There are differences between international health plans and Russian DMS (voluntary medical insurance) that provide benefits management solutions.
The Russian health insurance market in Russia and CIS has some specific features. The staff of Russian companies are usually covered by DMS. DMS for middle-level staff is usually not very expensive, but DMS for senior management can be more expensive than international plans. Besides the fact that DMS is more expensive, patients have access only to a few clinics in the city of residence. As a result the Russian client does not expect financial security from DMS (there is very limited number of clinics). Instead, the client expects that DMS will organize all medical services for them and will work as a medical concierge rather than a financial institution. Because of that expensive DMS for senior management is often accompanied by the services of a “coordinating doctor” – this is usually the employee of the insurance company who is responsible for organizing out-patient and in-patient treatment, coverage clarification, financial issues etc. The insurance company also asks for all medical and financial information from the healthcare provider. The insured usually has nothing to do with any claim forms, bills, medical reports etc.
International plans primarily provide financial security. Patients have access (cashless or “pay and claim”) to any medical facility they prefer. The insurance company can make recommendations about medical facilities with direct billing arrangements via a preferred providers’ list on the web or by telephone. It is not involved in organizing treatment.
There is another very important difference between international plans and Russian DMS. When a Russian client visits the clinic, he is usually confident that if he is not charged this means that the clinic received approval of coverage from the insurance company before or during the visit. When Russian clinics work with DMS they have two options: Option One – the insurance company has provided the clinic with the coverage plan and it is the clinic’s responsibility to identify whether the case will be covered or not (if the clinic makes a mistake very often it is covered neither by DMS nor by the patient). Option Two – at the time of the visit the clinic calls the insurance company to get approval.
When the patient is covered by an international plan it is possible to check the coverage at the time of treatment only in case of hospitalization. In case of out-patient treatment usually the decision about coverage is made when the insurance company receives a complete medical report.
If the insured is an expatriate these differences doesn’t usually cause any problems but if the international company would like to compete with local insurance company and enter the market of Russian clients it is necessary to take into account the fact that even though the Russian plan provides less financial security It provides more specific services that are essential for Russian clients.
In some cases expatriates are covered by international plans and are also covered by some Russian DMS. There is duplication of coverage and usually there is no connection between the international and the Russian insurance company. There is no primary insurance and secondary insurance. TPA allows clients to determine proper primary and secondary insurance. In this case both companies can benefit because the payments can be shared.
Neither Russian clients nor clinics (with the exception of international style clinics) are familiar with conditional and unconditional deductibles, co-payments, co-insurance, excess fee. TPA provider as claims adjustor helps all parties to deal with those items.
Some corporate clients providing global benefits programs to their employees use self-insurance approach. That means that they take all the risks and medical expenses. The company pays the medical providers itself or via an insurance company. In this case the company has a direct interest in controlling medical expenses. Taking into account the fact that the staff of non-insurance corporations usually have no great involvement in the healthcare market, TPA benefits-administration provider allows you to optimize the quality of medical services and the costs.