The problem
- Services are delivered but never billed, or billed late, and nobody can say how often.
- A new electronic medical record (EMR) or billing system went live, and some items quietly stopped billing.
- Revenue appears to fall after a Medicare Benefits Schedule (MBS) change, and nobody can tell real losses from a value-neutral restructure.
- Private practice and bonus arrangements are complex, and the health service and its doctors don't agree on what was earned.
- Bulk-billed claims are sitting in ageing worklists. Since 5 September 2025, most have one year to be claimed, not two.
- Management reports say one thing, the source data says another, and the board needs to know which is right.
Four ways in
Billing and claiming diagnostics
Each service is followed from activity through charge capture, claiming, receipting and payment. MBS billing analytics by specialty and item separates genuine anomalies from rule changes, and your claim time-limit exposure is sized.
02Private practice and bonus reviews
Private practice and bonus entitlements recalculated from source data, then reconciled to the payment runs. Both sides get numbers they can test.
03Revenue process and controls
The end-to-end revenue process mapped, with control points and an issues register for every stage, showing where it breaks and who owns the fix.
04Independent validation
Another team's findings re-run from the raw data against a formal testing schedule, with a clear report on whether they stand up.
Eight stages to finding health service revenue
A structured method, not a spot check. Eight stages and five reconciliations reach beyond the ledger to specialist payments and the controls that keep fixes in place. Full-population data is used wherever it exists, so gaps are traced to their root cause, fixed and retested, whatever patient administration, billing or finance systems you run.
- 1EntitlementWhat can be billed, and what must be paid?
- 2AccessIs this patient billable, and to whom?
- 3ActivityWas every billable service captured?
- 4ChargeDid it become a valid charge?
- 5Claim & cashWas payment received in full and on time?
- 6LedgerIs it recorded correctly?
- 7DistributionWas the right amount paid to the right person?
- 8ControlIs it fixed, and staying fixed?
- R1Activity against charges raised
- R2Charges against claims and worklist exits
- R3Claims against funder outcomes and cash
- R4Billing and cash against the ledger
- R5Ledger against specialist payments
A generic illustration of the method. It contains no client information, and client process maps are never published.
What a review delivers
- A process map of the designed revenue cycle and its key controls, in plain language.
- A findings and evidence register: each finding traced to data and labelled verified, corrected or awaiting explanation.
- A data request and question list that is clear about what the data can and cannot show.
- Options and a costed next phase by work area, so you choose where to go deeper.
Principles
- Data-led, from source. Results rebuilt from raw billing, payroll and payment data, not management reports.
- Honest about limits. A clear statement of what the evidence supports, what it doesn't, and what data is missing.
- Every finding is traceable. Each finding links to a register entry, a test and its source data.
- Sensitive by design. What goes in writing is kept separate from what is briefed in person, and what's shareable from what stays confidential.
Fixed fee, sample first
- ScopeThe question, the sample and the data extracts agreed up front, at a fixed fee.
- Diagnostic on a sampleThe method run on a sample of your services and payment runs, using your own systems and data.
- Results you can testYou see the themes, the evidence behind them and the data limits before you commit to anything more.
- Targeted follow-onA fixed-fee or capped engagement on the areas worth pursuing, ending in recovery, control fixes and monitoring.
Experience includes
Proof
Frequently asked questions
Is this an audit?
No. It is a management assessment: an independent, evidence-based view of what is happening and what to fix. It is not an audit or an assurance engagement under Australian auditing and assurance standards. Many clients share the findings with internal audit or their audit committee.
What data do you need?
Read-only extracts from your patient administration, billing and finance systems, plus payroll and payment data where private practice or bonuses are in scope. The list is agreed during scoping.
How do you tell real revenue loss from an MBS change?
Billing is analysed by specialty and MBS item, and each trend is lined up against MBS item and rule changes, so value-neutral restructures aren't reported as losses.
What is the Medicare time-limit risk?
From 5 September 2025, bulk-billed services are paid automatically only if claimed within one year of the date of service. Services before that date keep two years. Ageing worklists can now cost real revenue. Source: Department of Health, Disability and Ageing MBS factsheet, last updated 8 September 2025.
How do you handle industrially sensitive findings?
What goes in writing and what is briefed in person is agreed up front, along with what can be shared and what stays confidential.
Do you offer this in New Zealand?
The New Zealand team runs revenue maximisation for general practice and urgent care, on a contingency model.