TPA Executive /Sr. Executive Job Description in hospital

 

Departmental goal :  

 

To ensure efficient billing and that all approvals are submitted/ received on time. All package cases are managed within the package limit.             

                       

 Post‘s goal:

 To ensure timely receipt/application of appropriate approvals.

Submission of request for additional approvals. Timely close of the final bill and dispatch to the TPA for final approval.

                          

 Duties:

 

TPA Admission:

 

·         Verification will be done whether the TPA is impaneled with us and only those patients who are impaneled will be given cashless admission facilities.

·         Will check for the documents required at the time of admission:

·         Health insurance card copy

·         Check the validity of the insurance policy

·         Rockland doctors admission card/ request.

·         Photo ID proof (Voter ID/Pan card/Driving License/Passport)

·         Corporate Policy copy

o   Emp ID

·         Individual Policy

o   Insurance policy copy

·         Ortho Patient

o   MRI/Xray report

·         Gynae Patient

o   Latest Ultrasound

·         Positive finding reports

·         Will issue a pre-authorization form/request form to the attendant and get it filled with the relevant details along with signature and contact number.

·         For Corporate credit cases Credit limit is to be entered by the corporate counselors / Remarks to be entered by PCC doing admission.

·         In case of emergency admissions, the patient will be admitted and an emergency authorization will be FAXED to the TPA concerned.

·         Will ask the attendant/patient to make a refundable deposit of Rs.10000/- to cater for the expenses In case the cashless approval is not given.

·         Will take the form to the treating doctor and get the required fields filled

• Will check with the billing department for the estimate for any surgery/ conservation.
• Then send it to TPA for final approval.

 

• Estimate for medical:
• Room Rent
• Nursing care
• Doctors visit charge
• Investigation
• Pharmacy
• Consumable

 

• Estimate for Surgery:
• Room Rent
• Nursing care
• Doctors visit charge
• Investigation
• Pharmacy
• Consumable
• Surgeon charges
• Surgeon fees
• Asst. Surgeon fees       
• OT Charges                  
• Gas Charges                
• Anastasia charges          
• For orthopedics/eye/gastro, patients will check with the doctors for any implant/.
• Will send the form along with the necessary documents to the TPA for approval.
• Will be in constant follow up with the TPA and note down the name of the person interacted with, date, and time.
• Will inform the patient about the initial approval.
• Action in case of surgery for a procedure covered by a package. 5 copies of the list of consumables will be made and distributed as follows :
• OT  1 copy
• Pharmacy 1 copy
• Case sheet   3 copies

 

• At the time of admission will After registration or in the case of an already registered patient, the OPD billing screen (module) will be opened and the details of the services to be billed will be entered at the appropriate space. (pl see the screenshots attached)
• The billing is done according to patient category (full payment or on concessional rates)
• The patient will be asked about the mode of payment and the entry made. Cheques are not accepted.
• A receipt is generated and the patient is directed to the appropriate department.
• After completing the billing compilation of the bill and other related documents as per category requirement for record or bill clearance.
• Checking the record of surgeries performed in the OT sheet, and making entries of miscellaneous consumables used.
• Verifying all the entries with HIS before discharge and preparation of bills.
• A copy of the bill generated should be handover to the front office/ cashier
• All credit bills are received a day back from the front office after verification of reports, and referrals, and after completion of other formalities bills are dispatched to the respective corporate as per the agreed terms.
• All Discounts (Corporate, ECHS, CGHS, and all rates differences. in HIS and agreed rates) should be verified and settled.
• If some outsourced investigation is to be done issue an Outsource Investigations number (OSR No.) & charge accordingly.
• Preparing tentative discharge planner from HIS and sending it daily.

 

·         Will intimate the TPA of any increase in the estimate.

·         Will forward the case summary and doctor's recommendation to the TPA for further approval.

·         Will maintain a minimum balance in HIS in case of ICU patients.

• Discharge procedure:
• Will send a copy of the final bill and discharge summary to the TPA for final approval.
• Will follow up with the TPA (Minimum 3hrs taken by TPA to give the approval)
• Will not discharge the patient till the approval come.

 

List of information:

 

• A daily list of admissions
• An estimate of the day of discharge will be made and entered into the tracker
• Others as per departmental policy
• Checklist of documents to be deposited – organization wise
• List of impaneled organizations.
• Record of money collected under cash/credit card/credit admissions
• Record of sponsor-wise patients