Revenue Cycle and Reimbursement
This domain tests the flow from scheduling to cash posting and the payment rules behind each dollar. Expect front-end controls, charge capture and documentation, denial management, KPI interpretation, and Medicare and commercial payment mechanics.
The three phases and their metrics
Front end: scheduling, registration, insurance eligibility, prior authorization, and point-of-service collection. Mid cycle: charge capture, charge master maintenance, coding, and clinical documentation integrity. Back end: claim edits, submission, remittance posting, denial and appeal management, and self-pay follow-up. Track net days in A/R (net A/R ÷ average daily net revenue), aging over 90 days, clean claim rate, initial denial rate, first-pass resolution, cost to collect, and point-of-service collections. Measure A/R net, never gross - gross A/R rises with charge master increases and says nothing about collectability.
Payment methods
Medicare inpatient uses DRG weight × base rate plus add-ons (IME, DSH, outlier); outpatient uses APC groups; physicians use RBRVS: payment = Σ (RVU × GPCI) × conversion factor, with work, practice expense, and malpractice components. Commercial contracts add per diems, case rates, stop-loss, and carve-outs; value-based arrangements add shared savings, withholds, and quality gates. Sequestration reduces Medicare fee-for-service payments by 2%.
Worked example
A procedure carries 1.5 work RVUs, 0.8 practice-expense RVUs, and 0.1 malpractice RVUs. Site GPCIs are 1.05, 1.10, and 1.00; the conversion factor is $33.00. Adjusted RVUs = (1.5 × 1.05) + (0.8 × 1.10) + (0.1 × 1.00) = 1.575 + 0.88 + 0.10 = 2.555. Payment = 2.555 × $33.00 = $84.32. A 2% sequestration reduction lowers it to $82.63.
Traps
- Confusing a rejection (front-end edit, never adjudicated) with a denial (adjudicated and refused).
- Posting contractual and administrative adjustments to the same account.
- Ignoring patient liability, which is frequently a fifth or more of net revenue.
- Assuming DRG payment rises with charges rather than with documented CC/MCC capture.