Medicare/Private Billing Forecast

This use case explains how to forecast Medicare and private billing for healthcare, clinics and allied health practices using Model Reef.

You will:

• Split activity between public scheme rebates and private billing.

• Model schedule fees, rebates and gap payments.

• Represent bulk billed versus privately billed activity.

• Apply claim and payment delays to capture cash timing.

Model Reef does not connect directly to Medicare or private insurer systems. It uses aggregated assumptions and imported billing data to drive a financial forecast.

When to use this pattern

Use this pattern when:

• You bill a mix of public scheme rebates and private fees.

• You want to understand the impact of payer mix on revenue and cash.

• You need to plan around claim processing times and payment delays.

• You want payer mix wired directly into clinic and group financials.

It is commonly combined with:

• Practitioner Utilisation Model

• Clinic Level Profitability

• Multi Clinic Consolidation

Architecture overview

1

Activity and payer mix

• Sessions or consults per practitioner type.

• Split between public scheme billed and private billed activity.

2

Fee and rebate structure

• Schedule fee or standard fee per service.

• Rebate per service.

• Gap payment per service where applicable.

3

Claim and cash timing

• Time between service and claim submission.

• Time between claim submission and payment.

• Patient payment timing for gap fees.

4

Financial outputs

• Revenue from public scheme and private components.

• Receivables where payment is delayed.

• Cashflow and working capital impacts.

1

Start from practitioner utilisation and sessions

Using the Practitioner Utilisation Model, ensure you have:

• Billable sessions or consults per practitioner type and clinic.

• These sessions available as drivers or variables by period.

For each practitioner type and clinic, create drivers for payer mix, for example:

• Public Scheme Share of Sessions - GP - Clinic A.

• Private Billing Share of Sessions - GP - Clinic A.

• Gap Eligible Share of Public Scheme Sessions where relevant.

These shares should sum appropriately across payers.

2

Define fee and rebate drivers

In the Data Library, create drivers such as:

• Schedule Fee per Session - GP.

• Public Scheme Rebate per Session - GP.

• Private Fee per Session - GP.

• Average Gap Payment per Session - GP.

You may vary these by:

• Practitioner type.

• Clinic or region.

• Service category (standard consult, long consult, procedure).

These drivers can be updated when schedule fees change or when you adjust private fee policies.

3

Build revenue variables per payer and clinic

For each clinic and practitioner type, create Revenue variables for each billing stream, for example:

• Revenue - Public Scheme - GP - Clinic A.

• Revenue - Private Billing - GP - Clinic A.

• Revenue - Gap Payments - GP - Clinic A.

Define formulas such as:

• Sessions - Public Scheme - GP - Clinic A = Total GP Sessions - Clinic A × Public Scheme Share.

• Revenue - Public Scheme - GP - Clinic A = Sessions - Public Scheme - GP - Clinic A × Public Scheme Rebate per Session - GP.

• Revenue - Private Billing - GP - Clinic A = Sessions - Private Billing - GP - Clinic A × Private Fee per Session - GP.

• Revenue - Gap Payments - GP - Clinic A = Sessions - Public Scheme Gap Eligible - GP - Clinic A × Average Gap Payment per Session - GP.

Ensure all variables are typed as Revenue.

You can then create aggregate variables or rely on reports to sum:

• Public scheme revenue per clinic and in total.

• Private billed revenue per clinic and in total.

• Gap revenue per clinic and in total.

4

Apply timing to represent claim and payment delays

Use timing settings on revenue variables to reflect:

• Delay between service date and claim submission.

• Delay between claim submission and payment from the public scheme or private insurer.

• Patient payment timing for gap and private fees.

Examples:

• Public scheme rebates paid 7 to 14 days after claim submission.

• Private insurer payments on 30 day cycles.

• Gap fees collected on the day of service for most clinics.

Set delays in the variable timing modal so that:

• P&L recognises revenue when the service occurs.

• Balance Sheet records receivables where payment is delayed.

• Cashflow and Cash Waterfall show cash inflows when payments are received.

5

Integrate billing into clinic and group views

Because billing variables sit within clinic branches:

• Clinic level P&L will show public scheme, private and gap revenue.

• Group level P&L will aggregate across clinics.

• Cashflow and Cash Waterfall will show payer specific timing effects when segmented.

Use dashboards and reports to display:

• Revenue by payer type per clinic and for the group.

• Payer mix trends over time.

• Receivables related to public scheme and private billing.

• Cashflow sensitivity to changes in claim timing or payer mix.

6

Use scenarios for policy and pricing changes

Clone the base model into scenario models that represent:

• Changes in public scheme rebates or schedule fees.

• Adjustments to private fee schedules or gap policies.

• Shifts in payer mix between public, private and self pay.

• Changes in claim processing times or bad debt assumptions.

In each scenario, adjust:

• Fee, rebate and gap drivers.

• Payer mix drivers per clinic and practitioner type.

• Timing assumptions for claims and payments.

Compare scenarios on:

• Revenue and margin per clinic and for the group.

• Cashflow and working capital requirements.

• Valuation effects for the group or network.

Check your work

• Session volumes and payer mix align with historical billing data when calibrated.

• Fee and rebate assumptions match current policy and fee schedules.

• Receivables and cash timing profiles resemble actual patterns.

• Scenario changes behave as expected when you simulate policy or pricing shifts.

Troubleshooting

Modelled public scheme revenue does not match historical claims

Check session counts, payer mix percentages and the rebate per session assumptions, and reconcile against actual billing extracts.

Gap revenue appears too high or too low

Confirm that gap eligibility and average gap per session assumptions reflect real practice, and that you are not double counting private and gap streams.

Cashflow looks too smooth or too volatile

Refine timing assumptions for claim batching and payment cycles and use realistic delay distributions if necessary.

Related guides

• Build a Recurring Revenue Forecast

• Build a Rolling Forecast

• How Forecast Logic Is Generated

• Scenario Selector