Krishna
Founder, ShylCare
I've watched a patient sit in an ER waiting area for four hours while the billing desk tried to reach the TPA helpline for pre-auth approval. The patient had a valid insurance card. The policy was active. The procedure was covered. But the admission was stuck because the pre-auth process was a mess.
This happens more often than anyone admits. And the frustrating part is that it's entirely avoidable.
Here's the full pre-auth workflow, step by step, the way it should run — and where it usually falls apart.
The moment a patient says "I have insurance," the clock starts. Your front desk needs to capture three things immediately:
Most hospitals capture the first two and skip the third. That's how you end up discovering at discharge that the patient's sum insured is exhausted — and you're holding a ₹2 lakh bill with no payer.
Before you even think about pre-auth, verify. Call the TPA or use their portal. You're checking:
I've seen hospitals skip verification because "the card looks valid." A card from 2024 doesn't mean the policy was renewed in 2025. Verify every time.
This is where things get procedural. The TPA needs a pre-auth request that includes:
The document checklist:
Common failure point #1: Submitting with an incomplete form. If the TPA's pre-auth form asks for ICD-10 codes and you leave it blank, the request goes to the bottom of their queue for "clarification needed." That's a 24–48 hour delay right there.
Common failure point #2: Wrong policy number. Seems obvious, but when a patient has a family floater policy and you enter their individual member ID instead of the policy number, the TPA system can't find them. The billing desk calls, waits on hold, gets bounced — and the patient is still in the waiting area.
Once submitted, a pre-auth request moves through stages: Submitted → Under Review → Query Raised → Approved/Rejected.
The problem with most hospitals is that nobody owns the tracking. The request goes in, and then someone checks "when they get a chance." Meanwhile the TPA approved it two hours ago and nobody noticed, or the TPA raised a query that's sitting in an email inbox.
You need a tracking system — even if it's a shared spreadsheet at first — that shows every pending pre-auth with its current status and the last action timestamp. Someone checks this every two hours at minimum.
Common failure point #3: Delayed follow-up on queries. The TPA asks for an additional document. Your team sees it the next morning. They gather the document by afternoon. They submit it by end of day. The TPA reviews it the following morning. That's a 36-hour delay from a question that could have been answered in 30 minutes.
Once the pre-auth is approved, you get an approval letter with:
Read the approval carefully. If you requested ₹1.5 lakh and got approved for ₹80,000, that gap needs a conversation with the patient before admission — not at discharge when the bill is already ₹1.5 lakh.
Treatment plans change. A patient admitted for observation may need surgery. A 5-day stay may extend to 12 days. The original pre-auth amount may not cover the actual cost.
This is where you submit an enhancement request — essentially a revised pre-auth with updated treatment details and cost estimates. The same document requirements apply, plus you need the original approval number.
The timing matters. Submit enhancements as soon as the treatment plan changes, not after the additional treatment is done. A TPA is far more likely to approve an enhancement for a procedure that hasn't happened yet than to retroactively approve one that already has.
At discharge, the final claim package goes to the TPA:
The discharge summary is the single most important document. If it doesn't tell a coherent story — admission diagnosis, investigations done, treatment given, discharge condition — the claim will get queried regardless of everything else.
Every step I described above involves timestamps, document checklists, and status tracking. On paper or in disconnected spreadsheets, things slip. A pre-auth submitted but not tracked. A query raised but not seen for 12 hours. An enhancement needed but submitted after the procedure.
When this workflow lives inside your hospital software, each step is a tracked status change. The system knows a patient is TPA from registration. It prompts for verification before admission. It flags missing documents before submission. It tracks approval status with timestamps. It alerts when a query is raised. It blocks discharge billing if the claim package is incomplete.
The difference isn't magic — it's just that nothing falls through the cracks when every step is visible and tracked.
We've built these workflows into ShylCare so you don't have to figure them out alone. See how it works.
We'll walk through your actual workflows — no generic demo, no slide deck.