Summary. New electronic medical record (EMR) and billing systems are a common point for health service revenue to leak. Items stop billing, charges aren't captured, item codes and fees are mapped wrongly, and claims stall in interfaces and work queues. A structured 30/60/90-day check, comparing billing by item before and after go-live, finds most of it early.

Why go-lives leak revenue

A new EMR or billing system changes how almost every service turns into a bill. Charging rules that lived in the old system, or in the heads of experienced staff, have to be rebuilt. Interfaces between clinical, patient administration and billing systems are new. Work that used to happen automatically now waits in a queue for someone to act on it.

Go-live projects are judged on whether clinicians can use the system safely, which is the right priority. Revenue checks often come later, if at all, and by then the gaps have been running for months. With bulk-billed Medicare services now subject to a one-year claim limit (see the explainer), late discovery costs more than it used to.

Five places revenue leaks

1. Items that stop billing. An item that was billed regularly before go-live drops to zero, or close to it. Usually the service is still being delivered, but the trigger that created the charge in the old system wasn't rebuilt.

2. Charge-capture gaps. The service is recorded clinically, but no charge is created, or it is created only when a clinician completes a step that the new workflow makes optional. These gaps tend to sit in particular clinics, procedures or staff groups.

3. Item code and fee mapping. Items, modifiers and fees are configured in tables. A wrong mapping, a missing effective date or an item linked to the wrong fee can under-bill or over-bill every time it is used. Over-billing matters too, because it creates rework and compliance risk.

4. Interfaces. Messages between systems fail, are rejected or arrive incomplete. Unless someone watches the interface error log, those services never reach billing.

5. Work queues. New systems route exceptions into work queues: missing referrals, eligibility checks, coding questions. If queues have no owner, or the volume is underestimated, claims age quietly. Under a one-year limit, that ageing has a cost.

Don't count on late lodgement to rescue a go-live

If go-live problems hold claims past the time limit, late lodgement is unlikely to help. Services Australia's guidance says it won't accept late claims due to an administrative issue, and software problems are among its examples. The only reliable protection is finding stuck claims early.

When a fall isn't a loss

Not every drop after go-live is leakage. Medicare Benefits Schedule (MBS) items change regularly: items are split, merged, renumbered or re-priced, and rules about when they can be claimed together change. If an MBS restructure takes effect around the same time as your go-live, billing for an old item falls and billing for a new one rises. Looked at by item, it can look like a loss. Looked at across the related items, it may be value-neutral.

The way to tell the difference is to analyse billing by specialty and MBS item, then line each change up against the MBS change history before calling it a loss. Without that step, teams can spend weeks chasing a problem that doesn't exist, and miss the one that does.

A 30/60/90-day post-go-live revenue check

First 30 days: watch the flow.

  • Compare daily or weekly billing volumes by clinic and item with the same period before go-live.
  • Watch interface error logs and work queues daily, and assign an owner to each queue.
  • List items with no billing since go-live and check each one with the clinic.

By 60 days: test the configuration.

  • Reconcile activity to charges for a sample of clinics: every service delivered should have a charge or a documented reason why not.
  • Check item code and fee tables against the current MBS and your own fee schedules, including effective dates.
  • Review rejected and held claims by reason, and fix the causes, not just the claims.

By 90 days: separate real loss from change.

  • Analyse billing trends by specialty and MBS item, and line them up against MBS changes in the same period.
  • Age every worklist and queue by date of service against the claim time limit.
  • Write up what was found, what was fixed and what is still open, and agree who keeps monitoring it.

If the go-live was months ago and none of this was done, it is not too late. Start with the 90-day steps, then work backwards.

What this means for you

  • Plan a revenue check into the go-live, not after it.
  • Compare billing by item, not just in total.
  • Give every work queue and interface log an owner.
  • Check MBS changes before calling a fall a loss.
  • Age backlogs by date of service against the claim time limit.

How Nova can help

Nova's billing and claiming diagnostics compare billing item by item before and after a system change, find charge-capture and mapping gaps, and separate real loss from MBS changes. Where the process itself needs fixing, revenue process and controls maps it end to end. Both start with a fixed-fee diagnostic on a sample of your data.

This article is a general guide, not billing advice.

Sam Mackenzie is a director, owner and founder of Nova Consulting, and a co-owner and director of Nova Health. A former palliative care nurse, he leads Nova's health analytics and revenue work. Read Sam's profile

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