Practice revenue leakage.

Revenue leakage is the gap between what a practice earned and what it was actually paid. It is uncomfortable to look at precisely because it is not caused by anything dramatic. Nobody made a bad decision. The work simply outgrew the hours available to administer it.

Where it usually hides

• Rejections that were noticed but never corrected and re-submitted
• Short-payments buried in remittances that were filed rather than read
• Claims that aged past the point where the scheme will still engage
• Work that was done but never billed at all
• PMB claims paid from day-to-day benefits
• Time spent by clinical staff on administration instead of patients

Why it stays hidden

Every one of those is individually small and individually explainable. None of them appears on a report titled revenue leakage. The practice sees a slightly lower month and moves on.

Finding it

Start with the age analysis and the remittances rather than the billing system, because that is where the difference between billed and received actually shows up. Group what you find by cause. The pattern usually becomes obvious within an hour, and it is normally a small number of recurring causes rather than hundreds of unique problems.

This article is general information about healthcare administration in South Africa. It is not legal, clinical or financial advice, and it does not describe the rules of any particular medical scheme. Always check the position that applies to a specific claim.