Hospital Revenue Consulting
Private hospital revenue is complex, and we can help you navigate this complexity to optimise your relationships with the health funds.
How We Can Help
Your private hospital is dependent on health fund contracts for the majority of its revenue. Too many facilities start with a poor understanding of the range of services that these organisations do and do not want to pay for, and how to go about engaging with them.
Health funds pay for services provided at private hospitals in different ways depending on the fund, the type of hospital and its casemix. The regulatory framework within which health funds and hospitals contract is also quite restrictive, making it important to have a basic understanding of relevant legislation.
We offer the most value when we’re involved with your healthcare venture before design begins. Leverage our expertise on your choice of location, casemix, model of care and scale.
Our Approach
opunake has in-depth experience in healthcare funding. We approach this from a technical and commercial background, rather than taking a legalistic approach.
Our goal is to help you develop a service which appeals to funds, patients and practitioners.
Our speciality is helping you to develop services that offer value to patients and that appeal to funds, opening up more possibilities for practitioners and patients alike.
Get Expert Advice Early
If you’re starting a healthcare venture that will be dependent on private health insurance for some of its revenue, get expert advice early.
The private health insurance landscape is constantly shifting. What seems like an attractive healthcare business to you may not be viewed in the same way by those expected to provide the bulk of the revenue.
On the other hand, there are areas of healthcare and approaches to service provision that are highly attractive to insurers.
A new healthcare venture will absorb huge amounts of your valuable time and capital so it’s vital that the direction is good from the outset.
Understanding the Complexity of Healthcare Funding
Learning how to record and invoice each of the 37 funds correctly is a significant task for a fledgling business.
The 37 funds are arranged into seven groups of companies and brands, and these arrangements vary somewhat by state. There are also two groups of non-fund payers.
Once you have agreed on contracts with each health fund, executing them can be complicated. Each fund operates in subtly different ways and employs different interpretations and rules about payments to healthcare providers.
Some reasons for this complexity are:
History
Hospital funding and private health insurance have been topics of discussion between the state and federal governments and the various sides of politics since the 1950s. Policy has changed often, new regulations have been implemented, and insurers have sought to differentiate themselves from their peers.
Regulation
The main piece of legislation which determines the nature of health insurance business is the Private Health Insurance Act 2007, and the range of rules which sit under this act. A bundle of other laws (for example about risk equalisation or prostheses) tackle specific areas of healthcare.
Objectives
The funds’ objective is to provide equitable reimbursement for each of the thousands of procedure types while encouraging high-value healthcare and discouraging low-value health care. New models of care which substantially reduce the costs of healthcare provision can be attractive to health funds, but difficult to implement within existing structures.