The Basics Of Healthcare Revenue Cycle Management


Successful healthcare organizations rely heavily on revenue cycle management. To keep your practice running, you must have a well-functioning billing department, which could cost you thousands of dollars in payer reimbursements, patient payments, and other revenues.
An establishment’s success depends on its ability to manage its revenue cycle thoroughly and effectively. In this guide to revenue cycle management, the basic revenue cycle concepts and their benefits are detailed below.

What Do We Understand By Revenue Cycle Management?

Health care facilities use revenue cycle management (RCM) to keep track of patient care episodes, from registration and appointment scheduling to the final balance payment.
To bring together healthcare’s business and clinical aspects, RCM combines administrative data, such as a patient’s name and insurance provider, with the treatment a patient receives and their medical data.
RCM relies heavily on the ability to communicate with health insurance providers. Physicians and hospital staff typically verify the patient’s reported insurance coverage before an appointment.
Coders and healthcare providers use ICD-10 codes to categorize a patient’s treatment after receiving it and paying any applicable co-payment. Care summaries with ICD and CPT codes are then sent to the patient’s insurance company, figuring out how much insurance covers and how much the patient pays.

What Influences The Revenue Cycle?

Both internal and external factors influence the collection of revenue.
Provider productivity, patient volume, and service fees are all variables that a healthcare organization has some control over. However, external factors, such as patient payments or insurance company claims reviews, are more challenging to influence.

  1. Lack of Digital Workflow
    Poor data quality and issues with the revenue cycle can occur if the digital workflow is not streamlined. It is also possible to eliminate lost paper documentation by implementing an electronic workflow that helps to seamlessly coordinate front and back communication.
  2. Value-Based Care and RCM
    RCM systems, according to some, will also help the industry move from fee-for-service reimbursement to value-based reimbursement in the long run.
    Payers and providers can better understand their patient population through the analytics of many of these RCM systems, such as the percentage of patients suffering from chronic diseases. They can also keep an eye on their claims data and identify any anomalies.
  3. Revenue Cycle Management Systems
    The billing records of patients are frequently stored and managed by healthcare providers through specialized revenue cycle management systems. By interacting with other health IT systems, such as electronic health records (EHRs) and medical billing systems, an effective RCM system can reduce the time between providing a service and receiving payment.
    An RCM system can save healthcare organizations time by automating tasks that employees previously performed. Administrative duties include reminders to patients, payers, and patients of outstanding balances and contacting insurers with specific questions when a claim is rejected.
    Additionally, RCM systems can save providers money by revealing the reasons for denied claims. By encouraging healthcare workers to enter all the necessary information for claims processing – an RCM system can reduce rejected claims.
    It also allows providers to understand better why some claims are denied so that they can address the issue and save them from having to resubmit or revise the claim. Providing proper reimbursement for Medicare patients also ensures that providers are compensated for their time and effort.
  4. Key Organizations and Vendors in the RCM Industry
    You must utilize prominent providers of RCM systems that are either stand-alone or integrated with EHR platforms.
    HFMA, a non-profit organization that advocates for healthcare finance professionals and promotes related standards and practices, is another crucial player within healthcare revenue cycle solutions.
  5. Eligibility Issues
    A crucial part of the process is communicating with health insurance providers. Claims that have been submitted but not yet received may be pending, rejected, or denied if they are not adequately managed after submission.
    Claims tracking can help raise awareness and reduce recurrences by determining where problems originate, for example, by choosing whether there are issues with specific procedures or codes.

Benefits of a Revenue Cycle Management System

Healthcare Revenue Cycle (RCM) software, normally a Practice Management product, is famous for many healthcare providers. At the same time, other providers may opt to choose RCM Outsourcing to ensure a complete and accurate understanding of ICD-10 codes.
There is an option to utilize RCM software separately or couple it with EHRs. Interacting with other EHR systems can help store and manage patient billing records and potentially shorten the period between seeing the patient, billing, and reimbursement.
When it comes to transitioning from fee-for-service reimbursement to value-based reimbursement, an RCM system may be able to help. In addition to these advantages, RCM systems can:
●    Provide possibilities for revenue review
●    Explain the reasons for a claim rejection
●    Ensure that Medicare patients are appropriately reimbursed.
●    Identify a patient’s insurance coverage and co-payment obligations
●    Correct and track unpaid claims with the assistance of error detection
●    Give workers reminders to enter information to save time and better understand claim denials
●    Automate tasks such as reminders for appointments and payments and contact insurers to resolve claim denials to save time

Managing the RCM Process

A provider’s financial viability can be protected from claims by examining and improving a company’s revenue cycle management (RCM) core operations systems.
An early focus on pre-registration issues may help identify eligibility issues that can prevent initial claim rejections, while RCM software may help to ensure timely reimbursements.


In today’s world, revenue cycle management (RCM) must deal with increasing levels of organizational complexity while also ensuring the organization’s financial stability in times of crisis, like COVID-19.
Data-driven methods can assist health systems in finding possibilities to increase income and sustain improvements as the organizations confront obstacles.