A payer asked to extend an approval still in force is being asked to continue. A payer asked to cover spending that already happened is being asked to forgive.
The two requests, and why they land differently
| Raised at ~85% consumed | Raised after exhaustion | |
|---|---|---|
| What is being asked | Extend a live approval | Cover spending already incurred |
| Clinical justification | Prospective — why the stay continues | Retrospective — why it already did |
| Assessor’s position | Deciding a continuation | Deciding whether to absorb a gap |
| If refused | Hospital and patient can still choose | Charges already committed |
| Documentation available | Current notes, live observations | Whatever was recorded at the time |
Why eighty-five per cent
The threshold is not magic; it is the point at which enough of the approval is consumed to justify the request and enough remains to absorb the turnaround. Trigger it too early and the request is speculative. Trigger it at a hundred per cent and every subsequent day is at risk.
Consumption, not calendar
Enhancement is often treated as a day-three ritual. That works only when spend is even, which it is not: an ICU day and a ward day consume the approval at different rates. Watching the amount rather than the date is what makes the trigger reliable across case types.
Questions we get asked
When should a hospital raise a pre-authorisation enhancement?
When consumption approaches the approved amount, conventionally around eighty-five per cent, rather than on a fixed day of the stay. Spend is uneven across case types, so a calendar trigger fires too early on some admissions and too late on others, and a request made after the approval is exhausted asks the payer to cover spending already incurred.
Why are late enhancement requests refused more often?
Because the question changes. An enhancement raised while the approval is live asks the assessor to authorise continued treatment, with prospective clinical justification. Raised after exhaustion, it asks them to absorb a gap that already exists, supported only by whatever was recorded at the time.
On the figures in this piece. Every rupee amount above is arithmetic on the assumptions stated beside it, not a market statistic. Where you need published Indian claim data with its source named, that sits on claim data. We publish no figure we cannot show the working for.