Revenue Cycle

Pre Cycle

Mid Cycle

Post Cycle

Post Cycle Denials

Patient Billing: The amount the patient is responsible to pay, after the insurance company has paid their portion

Appeal Procedure: If warranted, an appeal can be submitted for consideration of payment with pertinent information attached

Account Receivables: Responsible for following up on denied claims, for possible resubmission of corrected claim, to receive maximum reimbursement from the insurance companies

Secondary Insurance Billed: If the patient has a secondary Insurance, claim would be billed with primary EOB

Denial Management: Designed to drill into 835 Electronic Remittance Advice (ERA) to uncover the root causes leading to denials

Patient Payment Posting: Insurance Payment Posting:

• All payers either send an EOB (Explanation of Benefits) or ERA (Electronic Remittance Advice) towards the payment of a claim
• The revenue cycle staff/software program posts these payments immediately into the respective patient accounts, against that particular claim, to reconcile them.

Clearing House Rejection: A clearing house rejection comes from the intermediary and usually occurs because of an issue with medical coding or missing information

Claims Submission: The billing process involves a healthcare provider to:

• Resolve claim edit issues
• Submit claims electronically or hard copy depending on payer specifics

Auditing: Services include internal or external audits that validate clinical coding, DRG codes and documentation through software and personnel-specific or organization-wide approaches.

Pre-Registration: When the appointment for a patient is made, collection of all registration, including eligibility, benefits and authorizations, prior to patient's arrival for inpatient or outpatient procedures:

• Verification of patient demographics information
• Verification of insurance coverage
• Identification of self-pay balances (including co-pays and deductibles)
• Obtain pre-authorizations (if needed)

Registration: Collection of a comprehensive set of data elements required in establishing a Medical Record Number and satisfying regulatory, financial and clinical requirements:

• Obtain copy of all insurance cards (primary, secondary and tertiary coverage)
• Request a form of photo ID to verify patient's identity
• Verify Patient demographic information
• Collect all monies due from patient (self-pay balances, co-pays and deductibles
• Registration information documented in the system is usually automatically pulled onto the UB-04 or HCFA 1500

Charge Capture: Transform healthcare diagnosis, procedures, medical services and equipment into universal alphanumeric codes. The diagnosis and procedure codes are taken from the medical record documentation, such as transcription of physician's notes, laboratory and radiologic results etc.

Clinical Documentation Improvement (CDI): CDI is at the core of every patient encounter. To be meaningful, it must be accurate, timely and reflect the scope of services provided. Successful CDI programs facilitate the accurate representation of a patient's clinical care that translates into coded data