🇦🇺Australia

Unbilled or Delayed Medication Management Services

3 verified sources

Definition

Retail pharmacies deliver Residential Medication Management Reviews (RMMR), Quality Use of Medicines (QUM) services, and Domiciliary Medication Management Reviews (DMMR) but fail to claim within required timeframes. QUM services must be claimed quarterly in arrears by month-end deadline. DMMR (Item 900, AUD $180.65) limited to once per 12 months—overbilling risks denial. Manual ledgers create deadline drift.

Key Findings

  • Financial Impact: AUD 2,000–8,000 per pharmacy annually (unclaimed QUM base payments: AUD 125/quarter + AUD 12.50 per bed; unclaimed DMMR: AUD 180.65 per eligible patient annually; follow-up services: AUD 56.33–28.16 per service)
  • Frequency: Quarterly (QUM deadlines); annually (DMMR limits); ongoing in per-encounter billing
  • Root Cause: Manual claim tracking, lack of automated deadline alerts, insufficient eligibility/frequency verification before service delivery

Why This Matters

The Pitch: Australian retail pharmacies waste AUD 2,000–8,000 annually per location on unclaimed QUM and DMMR services due to missed quarterly deadlines and inadequate eligibility tracking. Automation of claim deadline management and eligibility verification eliminates this leakage.

Affected Stakeholders

Pharmacy Manager, Billing Administrator, Pharmacist

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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

Billing Scope Violations & Over-Claiming Risk

AUD 5,000–50,000+ per audit cycle (typical MBS recovery for ineligible claims: 10–50 services × AUD 180–250 per claim; potential compliance penalty under Health Insurance Act)

Quarterly Arrears Payment Delays & Accounts Receivable Drag

15–30 days A/R cycle extension per pharmacy; estimated working capital drag: AUD 5,000–15,000 annually (based on typical pharmacy MTM revenue AUD 60,000–120,000/year at 30% arrears float)

Billing Method Selection Error (Per-Encounter vs. Monthly Capitated)

AUD 8,000–20,000 annually per pharmacy (estimated from: monthly capitated loss if underestimating patient volumes = lost per-encounter upside; per-encounter loss if over-selecting without coding infrastructure = missed claims from poor documentation)

Documentation & Coding Errors Leading to Claim Denials & Rework

AUD 4,000–10,000 annually per pharmacy (estimated: 5–10% denial rate × 40–80 MTM claims/year × AUD 180–250 per claim × 2 hours rework per denial × AUD 30/hour labor cost)

TGA Enforcement Action & License Revocation Risk

Business closure/license revocation = 100% revenue loss (unquantified in sources; typical community pharmacy revenue AUD 500k-2M+ annually at risk); estimated enforcement investigation cost: AUD 5,000-15,000 in compliance remediation and legal fees

Manual Documentation Bottleneck & Service Capacity Loss

Estimated 15-30 hours/month of pharmacist time at AUD 50-80/hour (fully-loaded cost) = AUD 750-2,400/month per FTE = AUD 9,000-28,800/year per pharmacist; 2-5% revenue leakage due to lost/delayed scripts during manual documentation bottlenecks = AUD 10,000-50,000/year for typical community pharmacy (estimated AUD 1-2M annual turnover)

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