Umsatzverlust durch abgelehnte oder verfallene Optical‑Ansprüche

Definition

Australian optical extras typically provide fixed annual limits per member, e.g. around 200–250 AUD per year for optical.[2][1] Each person on a policy has an annual optical limit that resets every 12 months.[2] Patients often plan eyewear purchases to use these benefits before expiry, but Optometry Australia notes that health funds apply differing rules on when optical claims can be submitted: for example, nib allows HICAPS claims at time of order only if full payment is made and benefit cannot be used as a deposit, while Bupa requires the claim to be entered on the delivery date, though the service date may be backdated to the order date.[4] Confusion over these rules, and over when the ‘service’ legally occurs, is a known area in compliance audits.[4] Where practices mis‑time claims (e.g. lodging before delivery against fund rules) or mis‑code items, benefits can be denied. Furthermore, if the claim is lodged after the member’s benefit period resets (typically annually in January or July), the patient’s entitlement for the prior period is lost, and the fund will not pay.[1][2] In practice, this often results in either: (a) the practice discounting the invoice to the level of the expected benefit to keep the patient satisfied; or (b) the practice writing off the unpaid portion when collection from the patient is not commercially viable. A typical practice seeing 2,000–3,000 patients annually, with average available optical benefits of 200 AUD per patient, only needs 2–3% of claims to be mishandled or missed to lose 8,000–18,000 AUD in potential reimbursements annually. Additional revenue leakage occurs where non‑claimable upgrades (e.g. some lens coatings classified as non‑essential by funds like nib) are mistakenly presented as covered and then not paid by the fund, requiring re‑invoicing or discounts.[2] Over a portfolio of practices, these small errors compound into sizable revenue gaps.

Why This Matters

The Pitch: Optometry players in Australia 🇦🇺 lassen jährlich 10.000–30.000 AUD an erstattungsfähigem Umsatz liegen, weil Optical‑Ansprüche abgelehnt, falsch datiert oder nach Limit‑Reset gar nicht eingereicht werden. Automation of benefit checking, claim timing and documentation capture reduces write‑offs and recovers lost revenue.

Affected Stakeholders

Praxisinhaber, Optometristen, Front‑Office/Verkauf, Praxismanager

Related Business Risks