A hospital group finds care that was given but never billed
Consumables, procedures and bed days were recorded in clinical systems but did not always reach the bill. Matching clinical records to invoices found the gaps, and fixing the hand-offs closed them.
An illustrative scenario. The company is fictional and the figures show how the method works; they are not a client result.
The situation
A multi-speciality hospital group runs several hospitals, each with its own mix of clinical and billing systems. Care is recorded by doctors, nurses and pharmacists. Bills are prepared by the billing team, often from a different system.
Every hand-off between the two is a chance for a service to be delivered but not charged. Insurance and corporate patients added another layer: package rates, exclusions and approvals that changed what could be billed.
What we looked at
- Pharmacy and store issues of drugs and consumables, by patient
- Procedure and theatre records
- Admission, transfer and discharge times
- Final bills and insurance claims
- Package and tariff agreements with insurers and corporates
What we found
| Finding | How it happened |
|---|---|
| High-value consumables issued to a patient but not on the bill | Issue recorded in the store system, not passed to billing |
| Procedures billed under a lower tariff | Wrong code chosen at billing |
| Bed days short-billed | Transfers between wards not reflected |
| Items excluded from a package but not billed separately | Package rules not applied correctly |
| Claims submitted without items that were payable | Documents missing at submission |
What changed
- A daily match between clinical records and bills, before the patient is discharged.
- Package rules in the system, so exclusions are billed automatically.
- Exceptions to the right desk: missing items to billing, coding questions to the clinical coder, claim gaps to the insurance desk.
Why it matters
Unbilled care is revenue the hospital has already spent money to deliver. Finding it before discharge is far easier than chasing it afterwards.
See revenue leakage for how the checks work, or read Where revenue leaks: 12 places to look this quarter.