Reimbursement and Revenue Cycle: Following the Dollar End to End
The chain
Revenue cycle runs from scheduling and eligibility through registration, documentation, charge capture, coding, claim editing, submission, adjudication, posting, denial management, and collections. Every handoff is a potential leak. Auditors trace a service from the note to the charge to the claim to the remittance and back again.
Vocabulary that drives questions
- Charge description master (CDM): the line-item price list; an error there touches every claim using that line.
- NCCI edits and modifiers: bundling rules, plus the modifiers (25, 59, X{EPSU}) that unbundle only when clinically justified.
- Allowed amount: the contracted rate; the gap between charge and allowed is a contractual adjustment, not a discretionary write-off.
- Patient responsibility: deductible, coinsurance, copay.
- Clean claim rate, days in A/R, net collection rate: three metrics you should be able to compute.
Denials and appeals
Categorize denials by root cause (eligibility, authorization, coding, medical necessity, timely filing), fix the cause, and appeal what is winnable within the payer deadline. Track appeal outcomes; a denial written off without review is itself an audit finding.
Worked example
Gross charges $500,000, contractual adjustments $180,000, payments $280,000. Net collection rate = 280,000 / (500,000 − 180,000) = 87.5%. Against a 95% target, the gap points to denials and unbilled charges - not to pricing.
Traps
Confusing gross and net revenue; treating a contractual adjustment as bad debt; missing timely filing; and assuming a service is covered because it was authorized.
Rule of thumb
No charge without documentation, no claim without a code, no write-off without a documented reason.