Room caps affect everyone. Beyond that, each department has a characteristic clause, and knowing yours is most of the work.
The characteristic clause by department
| Speciality | Clause that dominates | Fixable at |
|---|---|---|
| Ophthalmology | Procedure sub-limit at volume | Pre-authorisation, per case |
| Orthopaedics | Implant cost and supplier invoice | Billing, at the point the implant is used |
| Cardiology | Consumables inside or outside the package | Package definition, once |
| Oncology (day care) | Day-care sub-limit and cycle authorisation | Before each cycle, not at the start |
| Maternity | Package versus actual length of stay | Admission, and at each stay extension |
| Nephrology | Recurring authorisation across sessions | Renewal, before the current one expires |
| Gastroenterology | Procedure classified as day care, billed as inpatient | Admission decision, at the point of order |
The pattern underneath
Two of these are definition problems fixed once — what a package contains, how a procedure is classified. The rest are recurring, and recur per case or per cycle, which is why they need a mechanism rather than a memo.
Recurring authorisation is the quiet one
Treatments delivered in cycles or sessions carry an authorisation that expires partway through. Nothing announces the expiry; the sessions continue, and the shortfall appears at settlement. This is the failure most easily prevented by a countdown and most reliably missed without one.
Questions we get asked
Which sub-limit causes the most deductions in a hospital?
It depends on the speciality, which is why a single hospital-wide answer misleads. Room-rent caps affect every department, but beyond that orthopaedics is dominated by implant documentation, oncology day care by cycle authorisation, and maternity by length of stay against a fixed package.
Why do cycle-based treatments lose money at settlement?
Because the authorisation expires partway through and nothing announces it. Sessions continue on the assumption that approval covers the course, and the shortfall only becomes visible when the claim settles. A countdown against the current authorisation, rather than the first one, is what prevents it.
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.