Verzögerte Kostenerstattung durch fehlerhafte oder verspätete Anspruchseinreichung

Definition

Australian optometry practices depend heavily on private health insurance Extras benefits for optical sales (frames, lenses, contact lenses). Major funds (Bupa, nib, Medibank, HCF, NIB etc.) require properly itemised receipts, correct categorisation (e.g. ‘Optical’), and clear, readable documentation; blurry images or incomplete information can lead to claim rejection or delay.[2][1] Optometry Australia notes that HICAPS and iSoft claiming agreements are not written specifically for optometry and that each health fund can set its own rules for when a claim may be lodged (e.g. NIB allows claiming at time of order only if fully paid; Bupa requires the claim on the date of delivery, with possible back‑dating of service date).[4] These differing rules cause confusion and compliance audits, forcing practices to spend extra time on follow‑up, resubmission and reconciliation when claims are not processed promptly. Claims paid by health funds are typically processed in about 5–10 business days after correct submission.[1] When claims are submitted late, incorrectly, or with documentation errors, practices experience longer accounts‑receivable periods, tying up working capital. A typical suburban optometry practice lodging hundreds of optical claims per month can easily see 2–4 hours per week spent on chasing missing benefits, clarifying dates of service, or resending documentation. Assuming an internal admin cost of ~35–45 AUD per hour fully loaded, this equals about 3,500–9,000 AUD per year in staff time, plus time‑value of delayed reimbursements of 5,000–15,000 AUD tied up for additional 2–4 weeks in edge cases where claims are rejected and re‑lodged. This drag on cash flow is exacerbated near health‑fund benefit year‑ends (usually January or July resets) where incorrect timing or missed submissions can cause the patient’s annual limit to reset, making it impossible to recover the expected benefit, leaving practices to either write off the shortfall or attempt to re‑bill patients.

Why This Matters

The Pitch: Optometrists in Australia 🇦🇺 lose 10–20 Stunden pro Monat und verzögern 5.000–15.000 AUD an Forderungen jährlich durch manuelle, fehleranfällige Einreichung und Nachverfolgung von Leistungsansprüchen. Automation of receipt generation, eligibility checking and claim submission/follow‑up shortens time‑to‑cash and reduces rework.

Affected Stakeholders

Praxismanager, Empfang/Front‑Office, Buchhalter/Finanzverantwortliche, Inhaber‑Optometristen

Related Business Risks