Every month we sit with a practice owner who has done the arithmetic and knows pure bulk billing is no longer viable for their practice, and who is frightened of the conversation with patients. The fear is reasonable; the change is survivable. This is the sequence we run, the script we train reception on, and a patient letter you can adapt.
This is operational guidance from running practices, not financial or legal advice. Fee levels, concession categories and messaging are decisions for each practice; model them with your accountant.
Phase 1 — The margin audit
Twelve months of appointment and billing data out of Best Practice or Cubiko. Calculate the practice’s cost per practitioner hour — rent, nursing, reception, software, consumables, everything — and set it against the bulk-billed yield per practitioner hour by doctor and by item mix. This is the number that tells you whether you have a billing problem or a productivity problem, and it sets the minimum gap that closes it. If you skip this step you will pick a fee by copying the practice down the road.
Phase 2 — The fee and concession matrix
Decide, in writing, who stays bulk billed. The matrix most Australian mixed-billing practices use keeps bulk billing for children under 16, Pensioner Concession Card holders, Commonwealth Health Care Card holders and DVA card holders, with a private fee and gap for everyone else. Some practices add students, some add aged-care residents, some keep chronic condition plan reviews bulk billed. The rule has to be simple enough for reception to apply without a supervisor and consistent enough that patients don’t compare notes in the waiting room.
Remember the interaction with the incentive programs: bulk billing incentive items still apply to the patients you bulk bill; the practice-level 12.5 per cent program does not apply to a mixed-billing practice.
Phase 3 — Front-desk scripting
Reception must never apologise for the fee and must never be surprised by a question. Train the script on the phone at booking, at online-booking confirmation, and at check-in:
“So our doctors can keep spending proper time with patients, from [date] [Practice] is moving to mixed billing. A standard consultation has an out-of-pocket fee of $[gap]. Children, pension and health care card holders and DVA patients are still bulk billed. We process your Medicare rebate straight back to your card at the desk, so you only pay the gap.”
Then the three answers reception needs ready: what if I can’t afford it (concession check, doctor discretion policy), why now (costs, time with patients), and can I still see my doctor (yes — nothing else changes). Role-play it. Twice.
Phase 4 — The 30-day multi-channel notice
- SMS to the active patient list through HotDoc or Bp Comms, thirty days out, with a link to the fee page.
- Email with the full letter below.
- Signage at reception and on the entry door.
- Website fee page updated, and the fee stated in online-booking confirmations.
- A one-line note in the doctors’ consult rooms so the doctor says the same thing reception does.
Patient letter template
Adapt the wording, keep the structure. Square brackets are yours to fill from the margin audit.
Subject: An important update to billing at [Practice name]
Dear patient,
From [date], [Practice name] will move from bulk billing to mixed billing for most consultations.
We are making this change so our doctors can keep offering the consultation times, continuity and experienced team you expect from us. Medicare rebates have not kept pace with the cost of running a practice, and this change is how we keep the standard of care where it should be.
What it means for you. Most consultations will have a modest out-of-pocket fee, paid at the end of your appointment. Your Medicare rebate is processed straight back to your card at the desk, so you only pay the gap.
Who will still be bulk billed. Children under 16, Pensioner Concession Card holders, Commonwealth Health Care Card holders and DVA card holders will continue to be bulk billed for standard consultations. [Add or remove categories to match your matrix.]
Our fees from [date]. Standard consultation: fee $[ ], Medicare rebate $[ ], gap $[ ]. Long consultation: fee $[ ], rebate $[ ], gap $[ ]. [Add other common items.]
If you have questions, or if paying the gap would be a genuine hardship, please speak with our practice manager — we would rather talk it through than have you go without care.
Thank you for your understanding and for continuing to trust us with your health.
[Practice manager name]
[Practice name] · [phone] · [website]
What we see go wrong
- No margin audit, so the gap is either too small to matter or large enough to empty the book.
- Concession rules reception cannot apply without asking.
- Notice sent a week out, or only by signage.
- Doctors not briefed, so patients hear two different stories.
- Terminals not set up for instant rebate processing, so the patient pays the full fee and waits.
We run the margin audit as part of a clinic audit and train the script as part of reception and practice manager training.
Quick answers
Will we lose patients if we stop bulk billing?
Some, and that is part of the model. Practices that keep bulk billing for children, pensioners, health care card holders and DVA patients, set a modest gap, explain it clearly before the appointment, and process the rebate at the terminal keep the large majority. Practices that surprise patients at the desk lose more. The 30-day notice and the reception script are what protect retention.
How much should the gap fee be?
It comes out of your own numbers: the cost per practitioner hour against the bulk-billed yield per hour. We do not publish a figure because it varies with rent, staffing and doctor mix. The letter template below leaves the fee fields for you to fill from your margin audit.
Does mixed billing affect the bulk billing incentives?
Yes. From 1 November 2025 the bulk billing incentive items can be claimed for any Medicare-eligible patient you bulk bill, so the patients you keep bulk billing still attract the incentive. The 12.5 per cent Bulk Billing Practice Incentive Program, however, requires the practice to bulk bill all eligible services for all eligible patients — a mixed-billing practice cannot participate. Model both before deciding. The program explained →
Do patients still need to assign their benefit?
For the consultations you continue to bulk bill, yes — under the modernised assignment of benefit process that commenced 1 July 2026. Privately billed consultations are claimed differently. What changed →
Fifteen years in medical practice operations. MBA, Melbourne Business School. Two medical centres built and sold; ten-plus centres overseen today. About Jamal →