Page 99 - MEDICAL AND HEALTH INSURANCE
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MEDICAL AND HEALTH INSURANCE
Insured must, of course, provide all assistance and documentation and the Insurance
company will pursue the case at their own expense in the subrogation recovery.
5.6 THIRD-PARTY ADMINISTRATION IN THE CLAIMS MANAGEMENT
Third-party administrators have developed considerably in Malaysia as more and
many insurers are engaging their services.
Their administrative functions include:
Customer servicing through a 24 hours helpline service for policy benefits
enquiry, claims enquiry and hospital admission
Negotiation with providers and panel clinics on pricing and overcharging issues
and negotiated case pricing
Utilization analysis reporting and advice to clients; and other related
information for management feedback
Administering claims from admission to discharge, vetting of the eligibility of
cover and the issuance of the guaranteed letter to the final discharge and
follow up
Third-Party Administration is commonly seen to be used by insurer who wishes to
concentrate on underwriting risks and marketing, rather than on claims
administration.
Other than that, big corporates also engage Third-Party Administration to handle all
claims administration on self-funded schemes to avoid paying a premium to the
insurance company and to manage their own utilization. In such a self-administered
programmed, they would pay a fee to the TPA, usually on the basis of 'per member
per annum'.
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