The pre-auth clock nobody is watching

Most Indian TPA and insurer contracts carry a notification requirement that is separate from the pre-authorisation itself: the hospital must inform the payer that an admission has happened, within a fixed window. Commonly 24 hours for emergency admissions and 72 hours for planned ones.

Miss it and the claim is usually not rejected outright. Something worse happens — the admission loses cashless status and converts to reimbursement. The family pays at discharge and claims it back themselves, over months. From the hospital's side the money still arrives, eventually, from the patient rather than the payer. From the family's side, the hospital promised cashless and did not deliver.

Why it gets missed

The clock starts at admission, which is a clinical event. The notification is an administrative one, usually owned by the TPA desk, which is not staffed at 2 a.m. when the emergency admission happens. By the time the desk opens, eight of the twenty-four hours are already gone, and the case sits in a queue with everything else that arrived overnight.

Nobody is negligent. There is simply no clock on the screen.

What a working notification process looks like

• The clock starts automatically at admission, not when someone opens the TPA file
• The window is per-payer, because they differ — do not hard-code 24 hours across every contract
• Escalation happens at a fraction of the window, not at expiry. An alert at hour 22 of 24 is a notification of failure, not a prompt
• The submission is blocked if it is incomplete, with the missing item named — an incomplete notification sent inside the window is not a notification

The enhancement request, which has the same problem

A pre-authorisation is approved for an amount. The stay extends, or a procedure is added, and the billed total crosses the approved figure. The enhancement request has to go before the crossing, not after.

In practice hospitals discover this at 100% — when the bill hits the approved amount. That is already late, because the enhancement takes time to approve. The threshold worth alerting on is closer to 85%, which leaves room to request, wait, and receive a decision before the ceiling is actually reached.

What to check this week

Pull the last three months of admissions that converted from cashless to reimbursement. For each one, find the admission timestamp and the notification timestamp. If the gap exceeds the payer's window in more than a handful of cases, the problem is structural, not individual — and it is worth fixing with a clock rather than a reminder.

Drapto tracks notification windows per payer from the admission event and flags enhancement requests at 85% of the approved amount. See the pre-authorisation layer →