From S Ravi
The Independent TPA Alliance acknowledges the concerns raised in an article published by FMT on Dec 9 titled Medical group slams interference of 3rd-party administrators in clinics.
We recognise the need for clear communication and greater transparency in Malaysias healthcare sector. This response aims to address misconceptions, clarify the role of TPAs, and emphasise the importance of collaboration in strengthening the healthcare system.
Understanding the role of TPAs
Third-party administrators (TPAs) play a vital role in managing corporate healthcare plans, ensuring cashless medical access, and streamlining claims processes for businesses, clinics, and patients.
Contrary to claims of interference, TPAs do not dictate medical decisions. Our role is strictly administrative, ensuring corporate healthcare policies are applied fairly and efficiently.
There is also a distinction between independent TPAs and large corporate-backed TPAs. Independent TPAs operate on transparent, ethical frameworks, prioritising clinic sustainability, while some conglomerate TPAs have business models that may create market imbalances.
Addressing concerns about clinic operations
It has been suggested that TPAs disrupt clinic operations and lower the quality of healthcare. This perception is inaccurate.
TPAs do not interfere with medical decisions but instead assist clinics by reducing administrative burdens, structuring payments, and managing corporate client expectations.
The true challenges affecting independent clinics include:
- The increasing presence of large pharmacy chains and telehealth services that offer direct patient care, bypassing clinics.
- Corporations negotiating directly with large clinic chains, limiting access for independent GPs.
- The growing dominance of multinational healthcare groups, which threaten the viability of small practices.
A 2024 industry survey revealed that 79% of clinics working with TPAs reported improved efficiency in claims processing, with an average reimbursement time of 21 days. These findings contradict the notion that TPAs create financial strain for clinics.
Clarifying misconceptions about medical data and treatment processes
Another misconception is that TPAs control treatment processes or manipulate medical data. The reality is:
- TPAs do not set medical treatment protocols or interfere in clinical decisions.
- Transparency in billing is essential. TPAs may request clarification on claims that appear inconsistent with standard practices, ensuring compliance with corporate benefit structures.
- Corporate clients, not TPAs, define coverage exclusions. TPAs simply administer these policies according to pre-agreed terms.
The role of TPAs in sustaining clinic operations
A survey by the Private Medical Practitioners Association of Selangor and Kuala Lumpur (PMPASKL) indicates that 48.5% of doctors rely on TPAs to maintain their practices. This underscores the value TPAs bring in ensuring operational stability for independent clinics.
Without TPAs, clinics would face:
- Greater administrative challenges in managing direct corporate healthcare contracts.
- Payment delays and financial uncertainties, disrupting cash flow.
- Confusion over corporate healthcare policies, leading to billing disputes.
Tackling payment concerns and enhancing financial stability
While TPAs manage claims processing, payments ultimately depend on corporate clients and insurers. Many delays stem from corporate payment cycles rather than TPA inefficiencies.
To address this, the TPA Alliance is actively advocating for:
- Corporate deposit requirements to ensure a steady flow of payments to clinics.
- Better communication between clinics and corporate clients to resolve disputes faster.
- Standardised payment timelines, reducing inconsistencies in reimbursement schedules.
Rather than opposing cashless healthcare models, the focus should be on refining financial frameworks and ensuring corporate responsibility in making timely payments to clinics.
Strengthening industry standards for greater transparency
The TPA Alliance supports balanced regulation to promote a fair and sustainable healthcare ecosystem. We propose:
- Standardised payment cycles (e.g., 30-45 days) to reduce financial disruptions.
- Transparent service fees to prevent overcharging and maintain fairness.
- Independent dispute resolution channels to address clinic-TPA concerns effectively.
- Prohibiting TPAs from owning or being affiliated with clinics to ensure neutrality and competition.
These measures will strengthen the industry and enhance trust among stakeholders.
A path forward: collaboration over conflict
Addressing Malaysias healthcare challenges requires cooperation, not division. The TPA Alliance welcomes ongoing dialogue with PMPASKL and GP associations to develop sustainable solutions.
To move forward, we propose:
- Regular engagement forums to discuss concerns and find common ground.
- Collaboration on financial policies to enhance clinic sustainability.
- Greater transparency from corporate clients in defining healthcare benefits.
Conclusion
The Independent TPA Alliance remains committed to fair, transparent, and ethical healthcare administration. By fostering open communication and advocating for balanced regulations, we can create a more efficient and equitable healthcare system.
We invite PMPASKL and other GP associations to join us in shaping a collaborative and patient-focused healthcare landscape. Together, we can build a stronger, fairer, and more sustainable system that benefits clinics, corporate clients, and, most importantly, patients.
S Ravi is the spokesman for TPA.
The views expressed here are those of the writer and do not necessarily reflect those of FMT.