TPA and insurance claims: a paperless workflow for hospitals

A paperless TPA workflow means the pre-authorisation request, the supporting documents, the query replies, the final bill and the claim itself all leave the hospital as files generated from the HMIS, with each step time-stamped and visible on one screen. The hospital stops chasing paper, the TPA stops asking for the same report twice, and the outstanding amount becomes a number you can read every morning.

Cashless patients are a growing share of admissions in private hospitals, and the insurance desk is where a hospital's cash gets stuck. The process is not complicated. It is just slow when it runs on printouts, WhatsApp photos and a register.

How does a cashless claim move today?

1. The patient arrives with a policy or a TPA card. The desk checks eligibility with the TPA and notes the policy details.
2. The hospital sends a pre-authorisation request with the diagnosis, planned treatment, estimated cost and the doctor's note.
3. The TPA approves an initial amount, raises a query, or rejects. Queries go back and forth until an approval exists.
4. During the stay, if the estimate is exceeded, the hospital sends an enhancement request with the reason.
5. At discharge, the hospital sends the final bill, discharge summary, investigation reports and the signed claim form, and waits for final approval before the patient leaves.
6. The claim is submitted and, weeks later, settled, usually with deductions. The hospital reconciles what was approved, what was paid and what was disallowed.

Every one of those steps produces a document, and every document is already inside the HMIS. The point of a paperless workflow is to stop recreating them.

What does a paperless pre-authorisation look like?

• The admission screen captures the payer: TPA name, insurer, policy number, card number, and whether the patient is under a government scheme.
• The pre-authorisation form is generated from the admission record: patient details, diagnosis with ICD code, treating doctor with registration number, planned procedure and the tariff estimate from the package or the itemised rates.
• The doctor's note and the initial investigation reports attach automatically from the record.
• The request goes out by email or through the TPA's portal, and the time it left is logged.
• The approval letter is uploaded against the admission, with the approved amount and any conditions, so that the ward and billing see it too.

How do you handle queries and enhancements?

Queries are where days are lost. A query arrives by email at 11 am, the insurance desk prints it, walks to the ward, finds the doctor at 4 pm, and replies the next morning. The fix is to treat a query as a task with an owner and a clock.

• Each query is logged against the admission with the time received and the person responsible.
• The doctor answers from their own screen, and the reply attaches the report or note the TPA asked for.
• Open queries appear on the insurance desk dashboard sorted by age, and the oldest is red.
• An enhancement request is raised from the interim bill when the running total crosses the approved amount, with the reason from the doctor's orders.

What should the discharge and claim stage include?

When these come from one record, the file is complete the first time, and the discharge does not wait for someone to find a report.

How do you track settlement and deductions?

Submission is not payment. The claim ledger tracks each claim from submitted to settled, with the approved amount, the amount received, TDS deducted, disallowances and the reason codes. Ageing by TPA shows who pays in 30 days and who takes 120. Disallowance reasons, read monthly, tell you which consumables to stop billing and which package rates to renegotiate. These numbers belong in the daily MIS under dues, because TPA outstanding is usually the largest debtor a hospital has.

What about government schemes and NHCX?

Government schemes such as PM-JAY run through their own portals and package lists, and the workflow is similar: pre-authorisation, treatment, discharge documents, claim, settlement. The HMIS should let the desk tag an admission to the scheme, apply the scheme package rates, and generate the documents in the format the portal wants. The National Health Authority is also building a National Health Claims Exchange under ABDM to standardise how claims move between hospitals, TPAs and insurers. As it matures, hospitals whose HMIS already produces structured claim data will have the shortest path onto it.

The TPA and insurance module in Healthixio covers payer capture at admission, pre-authorisation and enhancement documents from the record, query tracking, claim submission files and the claim ledger with ageing and deductions. If your insurance desk still runs on a register, ask us to show you the difference.

Frequently asked questions

Why are our TPA claims deducted even after pre-authorisation?

Pre-authorisation approves an estimate, not the final bill. Deductions usually come from items the policy does not cover, room rent above the patient's eligible category, consumables billed outside the package, or a final bill that exceeded the last approved amount without an enhancement request. A claim ledger with reason codes shows which of these is costing you the most.

How long should a hospital wait before following up on a claim?

Follow the ageing report rather than a fixed rule. Each TPA has its own pattern, and the report shows it within a few months. Set a follow-up at the point where that TPA's claims usually settle, and escalate anything older. The insurance desk should work the ageing list every week, oldest first, with the outcome noted against each claim.

Can the same workflow handle Ayushman Bharat PM-JAY patients?

Yes, with the scheme's package rates and document formats configured. The admission is tagged to the scheme, the bill uses scheme packages, and the discharge documents are generated for upload to the scheme portal. The claim then sits in the same ledger as TPA claims, so scheme dues and their ageing appear alongside the rest of your receivables.