Revenue Cycle Management
Following the dollar from scheduling to posting
The revenue cycle is a sequence, and exam questions often ask you to place an activity in the correct phase or identify the root cause of a denial. Front end: scheduling, registration, insurance eligibility verification, prior authorization, and point-of-service collections. Mid cycle: charge capture, clinical documentation, coding, charge entry, claim scrubbing, and claim submission. Back end: payer adjudication, remittance posting, denial management, patient billing, and collections.
Understand key terms: chargemaster, fee schedule, allowed amount, contractual adjustment, coinsurance, copayment, deductible, clean claim, remittance advice, and explanation of benefits. Know the difference between a technical and professional component, and between global, professional, and facility billing.
Denials fall into categories: eligibility, authorization, coding, medical necessity, timely filing, and duplicate claims. Prevention lives upstream, so the best answer is usually to fix registration or documentation rather than to appeal faster. Key performance indicators include days in accounts receivable, clean claim rate, denial rate, net collection rate, and first-pass resolution rate.
Compliance intersects here: the False Claims Act, Anti-Kickback Statute, and physician self-referral (Stark) law shape billing conduct, and upcoding or unbundling can be fraud.
Worked example: A claim is billed at $1,200, the payer allowed $800, and the patient owes 20% coinsurance. The payer pays $640, the patient owes $160, and $400 is a contractual adjustment. If the patient never pays, the balance is bad debt, not a contractual write-off.
Trap: Confusing write-offs with adjustments, or assuming a denied claim should always be appealed rather than corrected and resubmitted when the error is clerical.