🇦🇺Australia

Gap Payments on Non-Bulk Billed Services

3 verified sources

Definition

MBS covers 75-85% of schedule fees for many RACF services; gaps arise without bulk billing, leading to lost revenue if facilities subsidize or fail to recover.

Key Findings

  • Financial Impact: 15-25% gap per service (e.g., $6-10 on $42 GP consult; $20+ on $82 item)
  • Frequency: Per non-bulk billed allied health/pathology in RACF
  • Root Cause: Failure to meet bulk billing incentives or track concessional patients (MMM 1-7)

Why This Matters

The Pitch: Nursing homes in Australia 🇦🇺 forfeit 15-25% Medicare benefits ($10-20 per service) due to non-bulk billing. Automation flags bulk incentives (10990/10991) to capture full rebates.

Affected Stakeholders

Revenue Cycle Manager, Clinical Billing Officer

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Financial Impact

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Current Workarounds

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Methodology & Sources

Data collected via OSINT from regulatory filings, industry audits, and verified case studies.

Evidence Sources:

Related Business Risks

MBS Billing Non-Compliance Fines

AUD 5,000-50,000+ per audit violation (typical PSR penalty range; full rebate clawback)

Non-compliance Fines for Care Plan Documentation Failures

AUD 50,000 - 500,000 in fines/penalties per audit failure; lost funding subsidies up to 100% of revenue for non-compliant providers

Lost Government Subsidies from Documentation Gaps

AUD 1,000 - 5,000 per resident per month in lost subsidies; 20-30% revenue leakage for non-compliant documentation

Staff Time Waste on Manual Care Plan Development

20-40 hours per resident per year at AUD 50/hour = AUD 1,000 - 2,000 per resident; 5-10% staff capacity loss

Produktivitätsverlust durch Kommunikationsfehler zwischen Pflege, Küche und Ernährungsberatung

Logic-based estimate: 360–1,080 hours per year of avoidable rework and communication time in a mid-sized home, worth ~$25,000–$50,000 AUD in labour plus $5,000–$30,000 AUD in wasted food and missed billable care opportunities, i.e. $30,000–$80,000 AUD annual capacity loss.

Delayed Discharge Bed Blockage

AUD 1,200-2,000 per bed per day in lost revenue (industry avg. nursing home bed day rate)

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