TPA & Insurance Claim Management
From pre-authorisation to final settlement — one team, every TPA, every insurer.
TPA and insurance coordination is the single most operationally complex function in hospital revenue cycle. Pre-authorisations, enhancements, queries, denials, document submissions, portal management, EOB reconciliation, grievance escalation — each insurer and TPA has its own rules, rhythm, portals and quirks. Our TPA & Insurance Claim Management service runs the whole function as a single, owned workstream — so admissions, doctors and finance don't have to.
Where Hospitals Lose Revenue
TPA and insurer coordination breaks down in hospitals for predictable reasons:
Pre-auth delays
Patients wait at admissions because pre-auth submission isn't immediate or follow-up is sluggish.
Enhancement misses
Treatment exceeds the approved pre-auth amount and the enhancement isn't requested in time.
Discharge clearance lag
Patient ready for discharge but final approval sits with the TPA, causing bed-block and patient frustration.
Portal fragmentation
Each TPA's portal works differently; small operational details get missed in the switching.
Reimbursement assembly chaos
Reimbursement claims need a different document set than cashless, and the assembly often runs late.
Document verification gaps
Insurer-specific document requirements aren't applied consistently, leading to queries.
Weak escalation when settlement stalls
Insurer commitments missed and the case just sits — no defined escalation path.
Each is operational, fixable and well within reach of a dedicated TPA cell — which is exactly what we run.
A Dedicated TPA & Insurer Cell — Full-Cycle Ownership
Our TPA cell owns the full insurer-facing cycle from admission to settlement. Pre-authorisation is initiated within minutes of admission triggering, with required documentation pulled from the EMR. Enhancement requests are anticipated and submitted before the threshold is breached, not after.
Discharge clearance is run as a tight pre-discharge protocol — final bill validation, document set assembly, TPA submission, query handling and approval, all converging into a same-day or next-day discharge experience for the patient and family.
For reimbursement claims (where the patient pays first and the insurer reimburses), our cell handles the assembly of the patient claim file — discharge summary, investigations, bills, payment proof, claim form and any insurer-specific add-ons — and submits on the patient's behalf with full follow-through.
Portal management for each TPA and insurer is held by named owners. Empanelment status, rate card validity, network panel renewals and document submission patterns are all tracked actively. When settlement stalls or commitments slip, defined escalation matrices take the case up the right ladder — processor, team lead, branch, grievance, regulator — until resolved.
Service Workflow
Admission to settlement — every step owned by the TPA cell.
- 1Pre-Auth Submission
- 2Pre-Auth Follow-up
- 3Enhancement (If Needed)
- 4Discharge Clearance
- 5Final Bill Submission
- 6Query Handling
- 7Settlement Follow-up
- 8Reconciliation Handover
Key Features
Everything included as a single, managed engagement.
Pre-Auth Processing
Pre-auth submitted within minutes of admission with documentation pulled from EMR.
Cashless Approval Coordination
Continuous follow-up through approval, enhancement and final clearance.
Discharge Clearance
Tight pre-discharge protocol so patients leave the same or next day, not after a TPA wait.
TPA Portal Management
Named owners for each TPA portal; submission patterns and quirks captured per portal.
Reimbursement Claim Assembly
Full reimbursement file assembled and submitted on the patient's behalf.
Document Verification
Insurer-specific document requirements applied per claim to prevent queries.
Insurer Relationship Management
Continuity of relationship with insurer claims teams across our owned slices.
Network Panel Coordination
Empanelment status, rate card validity and panel renewal tracking.
Empanelment Support
New TPA and insurer empanelment, renewal cycles and contract negotiation support.
Settlement Follow-up
Active follow-through on every commitment through to bank receipt and EOB capture.
Benefits
Measurable improvement across the metrics that move hospital finance.
Increase Collections
Recover what's owed faster and reduce the share of write-offs.
Reduce Denials
Catch documentation, coding and authorisation gaps before submission.
Reduce Claim Turnaround Time
Shorter cycle from discharge to insurer settlement.
Improve Cash Flow
Predictable, faster realisation of money already earned.
Recover Lost Revenue
Identify and reclaim missed billing, partial deductions and leakage.
Transparent Reporting
Real-time dashboards visible to finance leadership and management.
Dedicated RCM Team
A named team that knows your hospital, TPAs and patient mix.
Scalable Operations
Capacity flexes with claim volume — no in-house hiring overhead.
Industries Served
Healthcare organisations across India trust our RCM expertise.
- Corporate Hospitals
- Multi-Speciality Hospitals
- Single Specialty Hospitals
- Day Care Centres
- Cancer Hospitals
- Eye Hospitals
- Orthopaedic Hospitals
- IVF Centres
- Mother & Child Hospitals
- Dialysis Centres
- Diagnostic Centres
- Healthcare Chains
Performance Metrics
Numbers to be confirmed against the engagement and your hospital's baseline.
Why Choose Us
An enterprise-grade RCM partner, built around hospital realities.
Healthcare Domain Expertise
A team that has spent years inside hospital billing, TPA desks and insurance claim cycles — not a generic BPO retrained on healthcare.
Dedicated Billing & Recovery Team
A named account manager, a coding reviewer and an AR follow-up pod that knows your hospital, your TPA mix and your insurer relationships.
Technology Driven
Workflows orchestrated on a secure billing & recovery platform with audit trails, SLA timers, denial-pattern analytics and automated insurer follow-ups.
Data Security & Privacy
ISO-aligned controls, role-based access, encrypted transmission, secured storage and patient-data handling that maps to DPDP, HIPAA and HL7 best practices.
Transparent Reporting
Live dashboards covering claim status, AR ageing, denial trends, deductions and collection performance — visible to your finance leadership in real time.
Scalable Operations
Capacity scales with your monthly claim volume, peak surgical days and seasonal load — no recruitment burden on your finance team.
Compliance Focus
Coding aligned to ICD-10, CPT and HCPCS where applicable, plus discipline around CGHS, ECHS, ESIC, DGEHS, PSU and PMJAY scheme rules.
Continuous Process Improvement
Monthly root-cause reviews on denials, query patterns and leakage — feeding fixes back into your billing, documentation and EMR workflows.
Frequently Asked Questions
The questions hospital finance and operations leaders ask before they engage.
Faster Pre-Auth. Cleaner Discharge. Predictable Settlement.
A dedicated TPA & insurer cell — from admission to bank receipt.
Or explore the full Hospital Billing & Recovery Services catalogue.
No inflated promises. Documented scope, agreed KPIs and reporting you can audit.
Healthcare regulators rightly distrust guaranteed-outcome marketing — and so do we. Before we start, we put deliverables, KPIs and review cadence in writing; every month, we report against them in accounts you own. That's the kind of accountability healthcare deserves.
Written Scope & KPIs
Deliverables, KPIs, timelines and review cadence signed before kickoff. No vague retainers, no hidden scope, no empty promises.
Transparent Reporting
Monthly reporting you can audit — spend, enquiries, bookings and content shipped, in your own accounts and dashboards.
Healthcare-Only Specialists
20+ years building digital presence for hospitals, clinics & specialist doctors. Every campaign is compliance-reviewed by design.
Your Data, Your IP
Full ownership of website, ads accounts, CRM, creatives and patient data — always. Zero lock-in, full transparency.
What healthcare teams say about working with us
Client statements about our CRM, systems and compliance-first process.
"ClinicBOOST brought every enquiry, follow-up and appointment into one CRM. Our front desk finally works from a single queue, and no patient enquiry slips through the cracks."
"The most healthcare-literate systems team we've worked with. Every creative is compliance-reviewed before it ships, and the CRM reporting shows exactly where every rupee went."
"From website to WhatsApp to CRM — one connected system. Scheduling, reminders and follow-ups run themselves now, and we stopped juggling five separate vendors."
Get a healthcare growth plan built for your speciality.
Share a few details about your hospital, clinic or practice. Our team will audit your current digital presence and send a tailored growth roadmap within 24 hours.
- Speciality-specific patient demand analysis
- Conversion gap audit across web, ads, CRM & WhatsApp
- Compliance-safe creative & campaign blueprint
100% confidential. No spam. Healthcare team replies within 24 hrs.