Revenue cycle management (RCM) in US healthcare tracks revenue from patients and insurance from appointment scheduling to payment acceptance. The process involves several phases: front office procedures, provider services, billing and tracking, and payment follow-up, with different methods for submitting claims, such as paper or electronic claims. Errors in this process can lead to delayed or denied payments, making efficient management crucial for healthcare providers.

1. Revenue Cycle Management
US HEALTHCARE

2. RCM - Revenue Cycle Management
Revenue Cycle Management is the process used by healthcare industry in the
United States to track the revenue from Insurance company and / or patient.
• The Revenue Cycle Management process begins when a patient schedules
an appointment and it ends when the healthcare provider has accepted all
payments.
• Errors in Revenue Cycle Management can lead to the healthcare provider
receiving delayed payments or no payment at all.

3. • Patient’s data received
at Medical Billing
Company and Account
created
• Claim generated &
submitted
• Tracking of claim
• Payment or denial received
with EOB
• Posted to Patient’s account
and unpaid claims followed
up
• Balance due forwarded to
patient
• Full payment received or
forwarded to Collection
• Medical services
performed
• Medical records
generated
• Patient checks out of the
facility
• Patient’s appointment
• Insurance info received and
copied
• HIPAA & AOB signed by the
Patient
Phase 1
Front Office
Phase 2
Provider’s
Entity
Phase 3
Billing & Tracking
Phase 4
Payment & Follow-
up
Revenue Cycle Overview: Basic Steps in Processing an
Insurance Claim

4. Front Office:
• Patient’s appointment – Patient visits the Provider’s office
• Insurance info received and copied – Receptionist collects patient’s insurance
ID cards and keeps a copy
• HIPAA & AOB signed by the Patient – Patient signs all necessary documents
RCM - Phase 1

5. Provider’s Entity:
• Medical services performed – Provider sees the patient and performs medical services
• Medical records generated – Reports related to the medical service by the provider
generated
• Patient checks out of the facility – Patient leaves the Provider’s office
RCM - Phase 2

6. Billing & Tracking
• Patient’s data received and Account created – Provider sends Medical records to the
Medical Billing Company.
• Claim generated & submitted – Generate Claim through Software and submits to
Insurance company
• Tracking of claim – Claim is tracked through Websites and RM
RCM - Phase 3

7. Payment & Follow-up
• Payment or denial received with EOB – Post
adjudication we receive payment/denial along with
EOB
• Posted to Patient’s account and unpaid claims followed up – Post payment/denial as
per EOB
• Balance due forwarded to patient – Statement sent to patient if there is a patient
liability
• Full payment received or forwarded to Collection –
Close the account if full payment received or
forwarded to Collection agency if full payment
is not received.
RCM - Phase 4

8. Methods of submitting a claim:
Different methods exist for processing insurance claims. The most common are as
followed:
1. Paper Claims - After posting charges in Software and submitting to the insurance
payer on legacy paper CMS-1500 (Centers for Medicare & Medicaid Services) claim
form.
2. Electronic claims transmitted from Software. We partner with a Clearinghouse to
submit claims to the appropriate payer in the correct format.
3. Direct Data Entry (DDE) into the payer’s system. Specialist of billing industry would
log directly into the insurance company’s system and key in the information needed
to process the claim.

9. Claim Adjudication:
Claims adjudication is a term used in the insurance
industry to refer to the process of paying claims
submitted or denying them after comparing claims to the
benefit or coverage requirements.

10. Components of an EOB
• An explanation of benefits (commonly referred to as an EOB
form) is a statement sent by a health insurance company to
Providers explaining what medical services were paid or
denied.
• There is no standard format for EOBs from insurance
companies, but information contained in each one is usually
the same.

11. Claim Inquires and Follow Up Procedures:
The following are some reasons for making inquiries:
1. There was no response to a submitted claim within 45 days or a time
frame indicated by the AR Analysis
2. Payment received but the amount is incorrect
3. EOB shows that a professional or diagnostic code was change
4. Additional information / records are required

12. Any question?

13. Thank You
Santanu Patwari