Why cashless claims get queried, and how to stop it at the desk
Most TPA queries come from a short list of gaps that can be caught before the file leaves the hospital.
A query is not a rejection, but it costs the same thing: time. Every query adds days to the claim, and every day is money the hospital is waiting for.
Where queries come from
Across insurers and TPAs, the same gaps come back again and again:
- A document the payer expects is missing, such as an investigation report the bill charges for.
- Names, ages or gender do not match across the face sheet, the ID proof and the clinical notes.
- The timeline breaks: the discharge summary says one time and the nursing chart says another.
- A signature, stamp or registration number is missing on a doctor's note.
- The bill does not match the approved amount, or charges a room category that was not approved.
Catch it at the desk, not at the TPA
These are not clinical judgement calls. They are checks a careful person can make page by page, if they have the time. The trouble is that a discharge file can run to a hundred pages, scanned out of order, at the end of a busy shift.
What changes with a pre-check
When every file is read page by page against your own document checklist and the payer's list before it is sent, each desk gets a short list of what to fix: the doctor sees the missing signature, billing sees the missing pharmacy bill, nursing sees the gap in the chart. Fix, re-check, and send once.
More from the blog
Documents required for a cashless claim: the complete hospital checklist
The documents insurers and TPAs ask for most often, grouped by the desk that owns them, so nothing is missing when the file is sent.
Cashless claim process in a hospital: a step-by-step guide for the TPA desk
From the patient at the admission counter to the money in the hospital account: the eight steps of a cashless claim, and where each one goes wrong.