What delayed claims cost
These numbers are assumptions to replace with yours. A hospital files 100 cashless claims a month averaging ₹60,000, which is ₹60 lakh. If 15% of them are queried and delayed beyond 45 days, ₹9 lakh of receivables is stuck at any time, and it is the same ₹9 lakh that has to be funded from the hospital’s own cash for pharmacy stock, salaries and consumables. Beds earn only when they are full, so pair claim follow-up with your bed occupancy rate.
The usual reasons claims are queried or rejected
- Pre-authorisation was not obtained, or the final bill exceeds the approved amount without an enhancement request.
- Diagnosis and procedure on the discharge summary do not match the bill.
- Package rate for the payer was not applied, or charges outside the package were billed without approval.
- Documents are missing: discharge summary, investigation reports, implant stickers, signed consent, and ID and policy copies.
- Patient name, age or policy number differ between the admission form and the claim.
- Dates do not line up: admission, surgery and discharge dates differ across documents.
- Claim submitted after the insurer’s deadline.
- Non-payable items were billed to the insurer instead of the patient.
A pre-submission checklist
- Pre-authorisation approval and any enhancement attached to the admission.
- Package rate for this payer applied, and extras separated.
- Discharge summary signed, with diagnosis and procedure matching the bill.
- All investigation, OT and implant records attached.
- Patient and policy details verified against the original ID at admission.
- Final bill split between insurer share and patient share, with non-payable items on the patient’s side.
- Claim submitted within the insurer’s window, with the date recorded.
- A follow-up date set on every pending claim.
Where digital claim exchange fits
India is moving claim submission towards structured digital formats through the National Health Claims Exchange (NHCX) under the Ayushman Bharat Digital Mission. NHCX adoption is not legally mandatory for hospitals, but insurer and PM-JAY processes and incentives are pulling in that direction, so ask any software vendor, including us, in writing what it supports today. Read the circulars on the National Health Authority site.
Doing this in software
In Hospital ERP, insurance providers and policies, pre-authorisation with documents, claims with their documents, service packages with payer-specific rates and implant tracking sit in the same record as the admission and the bill, so the checklist above is a view of data already captured instead of a hunt through files. See the hospital software buyer guide for what to ask a vendor.
Frequently asked questions
Why do TPA claims get rejected?
The most common causes are missing pre-authorisation, mismatched diagnosis and bill, wrong package rate, missing documents, detail mismatches between forms, and late submission.
Is NHCX mandatory for hospitals?
No, it is not legally mandatory, but insurer processes and incentive schemes are pushing hospitals to adopt it. The NHA and IRDAI circulars have the current position.
What should be separated on the final bill?
The insurer’s share and the patient’s share, with non-payable items and anything outside the approved package billed to the patient, so the insurer is not queried for them.
Practical, India-specific guides from the team behind WebSoftOS cloud ERP, by Ridhi Technologies, Zirakpur, Punjab.