The three ways a surgical practice gets paid
Almost every dollar a private surgical practice earns arrives through one of three routes, and most patients involve more than one:
- Medicare. The Commonwealth pays a set rebate on eligible services, described by item numbers in the Medicare Benefits Schedule. For most surgery this is a partial payment, not the whole fee.
- Private health funds. For in-hospital treatment, a patient's fund pays its share — coordinated with Medicare through the ECLIPSE channel, often under a known-gap or no-gap arrangement.
- DVA and the patient. Department of Veterans' Affairs claims cover eligible veterans; anything left over is the patient's out-of-pocket, which should be agreed in advance through Informed Financial Consent (IFC).
What ECLIPSE actually is
ECLIPSE is the electronic claiming system that connects your practice, Medicare and the private health funds for in-hospital services. Instead of billing Medicare and each fund separately, a single ECLIPSE claim is routed to both and reconciled together. It's what makes known-gap and no-gap billing workable, and it's the backbone of how a surgical practice is paid for theatre work.
The trade-off is that ECLIPSE is unforgiving about detail. Provider numbers, fund membership, item numbers and agreement schemes all have to line up, or the claim bounces.
Why claims get rejected — and what good billing does about it
Rejections are normal; leaving them unresolved is what costs money. The usual culprits are mundane:
- • Expired or incorrect provider, location or fund-membership details
- • Eligibility or item mismatches against the fund's agreement
- • Missing or incomplete Informed Financial Consent
- • Assistant, anaesthetist or multiple-procedure rules not applied correctly
The fix is process, not luck: every rejected or short-paid claim is investigated, corrected and resubmitted, and outstanding accounts are followed up until they're paid. That's the difference between the income you earned and the income you actually bank. It's the core of what we do on our medical billing for surgeons service.
Who's responsible for a claim
This one matters. Under the Health Insurance Act 1973, the practitioner named on a claim is responsible for it — even when someone else lodges it. A good billing team works as an authorised delegate on your PRODA account, processes the item numbers you direct, and keeps a clean audit trail. It does not choose or vary item numbers on your behalf. Setting that access up correctly is covered in our provider number & PRODA setup guide.
Common questions
Is ECLIPSE the same as Medicare?
No. Medicare is the Commonwealth scheme that pays a rebate on eligible medical services. ECLIPSE is an electronic claiming channel — it carries in-hospital claims between your practice, Medicare and the private health funds so a single claim can be settled by both. You use Medicare's benefit schedule; ECLIPSE is the pipe the in-hospital claim travels down.
Can someone else lodge my Medicare claims for me?
Yes. A practice or an authorised delegate can lodge claims on your behalf through HPOS and ECLIPSE using your provider details — the same pathway your own reception staff would use. It is delegated access, not a shared login. Under the Health Insurance Act 1973 you, the practitioner, remain responsible for every claim made in your name.
What happens when a claim is rejected?
A rejected or short-paid claim should be investigated, corrected and resubmitted — not written off. Common causes are expired provider or fund details, eligibility mismatches, missing Informed Financial Consent, or a fund agreement that doesn't match the item claimed. The revenue is usually recoverable; it just has to be chased.