Summary: Cashless insurance claims involve pre-authorisations, documentation and follow-ups. A hospital ERP keeps the process organised and reduces revenue leakage.
For many Indian hospitals, a large share of revenue comes through health insurance and TPAs. Delays, rejected claims and missing documents directly affect cash flow.
The claim workflow
- Patient admission with insurance details
- Pre-authorisation request to the TPA or insurer
- Approval, partial approval or queries
- Treatment and billing as per approved packages
- Final bill and discharge documentation
- Claim submission and follow-up
- Settlement and reconciliation
How ERP helps
- Stores insurer and TPA tariffs and packages
- Tracks pre-auth status and approved amounts
- Alerts billing staff when costs exceed approval
- Organises required documents per claim
- Tracks pending claims and ageing
- Reconciles settlements with deductions
Reducing rejections
Common causes include missing documents, incorrect codes and exceeding approved limits. Checklists and alerts in the ERP reduce these errors.
Integration with clinical modules
Linking billing to clinical records ensures services provided are captured correctly.
Reporting
Management can see claim volumes, approval rates, settlement timelines and deductions by TPA.
FAQs
Can the ERP connect directly to insurers?
Some integrations are possible; many processes still involve portals and documents.
Does it handle government schemes?
Workflows can be configured for applicable schemes.
Can we track deductions?
Yes, by reason and insurer, to identify patterns.
