Pre-auth, query response, discharge note, final claim — a single connected workflow inside the EMR, not four separate Excel sheets and a TPA helpdesk on speed-dial.
Why TPA queries blow up turnaround
The cashless workflow in most Indian hospitals lives in three places — the EMR (clinical record), the billing software (charges), and an Excel sheet maintained by the insurance desk (pre-auth status, query log, settlement tracker). When the TPA raises a query, the insurance desk has to copy clinical context from the EMR, paste it into an email, attach a scan of a document, and follow up by phone. Average settlement time per claim hovers around 28-35 days in the hospitals we've audited, with 18-22% of claims sitting in 'query raised' status for over a week.
Pre-auth done right
- Pre-auth request drafted from the admission record — diagnosis, planned procedure, estimated stay, line-itemised cost.
- Treating-doctor confirmation built into the doctor's workflow, not a separate sign-off task.
- Submission to the TPA in the format the specific TPA expects — different TPAs accept different shapes, and the system should know each.
- Auto-attached documents — admission note, relevant labs, imaging — selected by the system, not searched for by the insurance desk.
- Status tracking back from the TPA, polled or webhooked, so 'approval pending' is a known state with a known wait.
Document attachment — the bit that wastes a day
The single most time-consuming task on the insurance desk is finding and attaching documents to a TPA query. The query says 'please share latest creatinine'. The insurance desk opens the EMR, searches the lab module, downloads the PDF, attaches it to an email, sends. Five minutes per query. If the EMR exposes a 'documents tab' on every claim with a one-click attach to the TPA portal, that five minutes becomes thirty seconds, and the desk handles 4x more queries per day.
Discharge summary tied to the claim
The discharge summary is the single most important document in the final claim — and it's also the document the doctor produces last. If the discharge summary doesn't include the items the TPA needs (final diagnosis with ICD code, list of procedures performed with CPT/ICD-PCS where applicable, complications during stay, discharge medication), the claim gets rejected for incompleteness and the patient has already left. Build the TPA's checklist into the discharge summary template so the doctor cannot mark the case discharged without filling them in.
Settlement tracking — knowing what's still pending
- Per-claim status — submitted, approved, query raised, query responded, approved with deductions, paid, rejected.
- Days-in-status — how long has this claim been waiting, and is the wait normal for this TPA at this volume?
- Deduction tracking — every rejection or part-rejection with the reason; pattern detection across claims (this TPA keeps rejecting room-rent over X).
- Payment reconciliation — when the TPA pays, the system matches it to the claim and flags any short-payment automatically.
Reconciliation: the AR ageing every CFO wants
Insurance receivables form the largest bucket of accounts-receivable in most multispecialty hospitals — and the slowest moving. A real AR ageing report breaks it down by TPA, by branch, by ageing bucket (0-30, 31-60, 61-90, 90+), with drill-downs to individual claims. The CFO can see at a glance which TPA is sitting on three crore in 60+ day claims and apply commercial pressure where it's needed. Without the report, the same three crore is invisible and gets discovered six months later as a write-off.
Quick wins
If you start with two things — auto-attach of documents to TPA queries, and a checklist-driven discharge summary — you've already cut your average settlement time by a week. The rest of the workflow is iteration, but those two pieces are the highest-leverage interventions we've measured across 200,000+ claims.