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Enhancing Medical Claim Approval Efficiency and Patient Satisfaction: An In-Depth Analysis of Third-Party Administrator (TPA) Rejections at Tertiary Care Hospital

Ravi Makhija, Dileep Singh Chauhan, Amit Joshi

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Attribution-Non-commercial 4.0 International (CC BY-NC 4.0)

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Journal of Hospital Administration 8(1):p 7-12, January-June 2024. | DOI: n.a

How Cite This Article:

Chauhan DS, Joshi A, Makhija R. Enhancing medical claim approval efficiency and patient satisfaction: an in-depth analysis of Third-Party Administrator (TPA) rejections at tertiary care hospital. RFP Journal of Hospital Administration. 2024;8(1):7-14.

Timeline

Received : April 19, 2024         Accepted : June 14, 2024          Published : June 30, 2024

Abstract

Background: Cashless medical claim denials by Third-Party Administrators (TPAs) can lead   to financial burdens and dissatisfaction among patients. Objective: To analyze TPA rejections at a tertiary care hospital, identify factors contributing  to cashless denials, and suggest measures to enhance claim approval efficiency and patient  satisfaction. Methods: The data for this study was collected through a retrospective approach from a  period of March 2023 to December 2023. The dataset included information related to Mediclaim claim rejections, patient details, comments from TPAs, discharge notes, and hospital remarks. Results: The study revealed a 25% cashless denial rate, primarily due to inadequate  documentation,40% followed by TPA response time delays and claim type discrepancies and (35%). Disease categories with highest denial rates were identified.   Conclusion: The pivotal role played by Third-Party Administrators (TPAs) in facilitating the  smooth disbursement of mediclaims and contributing significantly to the hospital's revenue  stream was evident. However, the study revealed that despite the critical role of TPAs, a   considerable number of mediclaim rejections were occurring, leading to conflicts between the  hospital, patients, and their families.

References

  • 1.   Bhat Ramesh & Maheshwari, Sunil Kumar & Saha Somen, 2005. “Third Party Administrators and Health Insurance in India: Perception of Providers and Policyholders,” IIMA Working Papers WP2005-01-02, Indian Institute of Management Ahmadabad, Research and Publication Department
  • 2.   Bennett W. E. (2020). Insurance Denials of Care Amount to Unlicensed Medical Practice. Journal of managed care & specialty pharmacy, 26(7), 822–824. https://doi.org/10.18553/jmcp.2020.26.7.822
  • 3.   Chuang KH, Aubry WM, Dudley RA. Independent medical review of health plan coverage denials: early trends. Health Aff (Millwood). 2004;23(6):163-69.
  • 4.   Tintinalli JE. Analysis of insurance payment denials using the prudent layperson standard. Ann Emerg Med. 2000;35(3):291-94.
  • 5.   Barkholz D. Insurance claim denials cost hospitals $262 billion annually. Modern Healthcare. June 27, 2017. Available at: https:// www.modernhealth-care.com/article/20170627/ NEWS/170629905/insurance-claim-denials-costhospitals-262-billion-annually.

Data Sharing Statement

There are no additional data available

Funding

This research received no funding

Author Contributions

All authors contributed significantly to the work and approve its publication

Ethics Declaration

This article does not involve any human or animal subjects, and therefore does not require ethics approval

Acknowledgements

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Conflicts of Interest

No conflicts of interest in this work

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Cite this article

Chauhan DS, Joshi A, Makhija R. Enhancing medical claim approval efficiency and patient satisfaction: an in-depth analysis of Third-Party Administrator (TPA) rejections at tertiary care hospital. RFP Journal of Hospital Administration. 2024;8(1):7-14.

Licence:

Attribution-Non-commercial 4.0 International (CC BY-NC 4.0)

This license enables reusers to distribute, remix, adapt, and build upon the material in any medium or format for noncommercial purposes only, and only so long as attribution is given to the creator

Received Accepted Published
April 19, 2024 June 14, 2024 June 30, 2024
DOI: n.a

Keywords

MediclaimTPAClaimDenialRevenue

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Timeline

Received April 19, 2024
Accepted June 14, 2024
Published June 30, 2024

licence

Attribution-Non-commercial 4.0 International (CC BY-NC 4.0)

This license enables reusers to distribute, remix, adapt, and build upon the material in any medium or format for noncommercial purposes only, and only so long as attribution is given to the creator


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