Honorarverluste durch abgelehnte oder gekürzte Leistungen wegen fehlender Vorabgenehmigung

Definition

International private insurers state that if treatment is provided without required pre-authorisation and is later found ineligible, they may decline the claim; even when eligible, they may only pay a portion of the cost.[1][5][8] In a typical physical/occupational/speech therapy practice where many block treatments (e.g. multi-week rehab programs, post-surgical therapy, complex paediatric therapy) require pre-approval for direct billing, failure to obtain or document prior approval converts what would have been reimbursable revenue into bad debt or patient disputes. Soft and outpatient managed-care style pre-approval is emerging in Australian private health insurance, where certain procedures now need pre-approval from the health fund despite policy entitlement.[4][7] When staff track pre-authorisation manually (fax, email, phone) and use spreadsheets, simple paperwork errors or missed deadlines drive denials, as noted generally for prior-authorization processes.[8] For an Australian allied health clinic billing, for example, 150–300 insured therapy sessions per month at an average AUD 90–120 per session, a 3–8% denial/partial-pay rate tied to pre-authorisation defects equates to AUD 4,800–34,500 in annual lost revenue. Where higher cost multi-session rehab programs (e.g. AUD 1,000–3,000 episodes) are denied or cut from 100% to 50% cover, two to five such events per year add another AUD 5,000–20,000 in write-offs. Combined, a realistic leakage band is AUD 20,000–60,000 per year for a mid-sized practice unless pre-authorisation/benefit verification is systematised.

Why This Matters

The Pitch: Therapy clinics in Australia 🇦🇺 waste AUD 20,000–60,000 pro Jahr on denied or underpaid claims caused by missing or incorrect pre-authorisation. Automation of benefit checks, authorisation tracking and alerts before treatment eliminates this revenue leakage.

Affected Stakeholders

Praxisinhaber:in / Klinikleitung, Leitende/r Physiotherapeut:in / Ergotherapeut:in / Logopäd:in, Abrechnungs- und Verwaltungsmitarbeitende, Finance Manager, Practice Manager

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