Revenue cycle management is billing plus everything on either side of it: checking coverage before the visit, catching the charges that never got entered, and comparing what the payer paid against what the contract says they owe. Our revenue cycle management services run the whole cycle for practices with 2 to 25 providers and report on it in numbers you can act on.
What revenue cycle management adds beyond billing
Billing starts when a charge exists. Revenue cycle management starts before the patient walks in and ends when the last patient balance is resolved. On the front end we verify eligibility and benefits for every scheduled visit through a 270/271 check, so copays and deductibles are collected at check-in and the CO-16 and PR-204 denials never get created. Procedures that need prior authorization are flagged before scheduling, because a CO-197 denial after the fact has no appeal worth filing. After the visit we reconcile the schedule against the charges entered, because a visit with no charge is money that never had a chance. Once payments post, we compare each allowed amount against your payer contract and flag underpayments. Patient balances get statements, then calls, on a schedule you approve.
The five metrics we manage
Days in A/R tells you how long it takes to get paid, and anything over 40 usually means claims are sitting somewhere. First-pass rate is the share of claims paid without being touched twice; when it drops, the scrubber or the front desk needs attention. Net collection rate compares what you collected to what you were contractually owed, and it exposes underpayments and lazy write-offs that gross collection rate hides. Denial rate by count and by dollars, tracked by CARC code and payer, tells you where the process is breaking. A/R over 90 days as a share of total A/R is the one most owners already know is bad. We report all five weekly, and the monthly call is about moving them. The clean claim rate benchmark article explains what good looks like for each.
Where the revenue actually leaks
It is rarely one big hole. It is missed charges, because a provider drained a joint during a 99214 visit and only the visit was coded, or gave a J3301 injection that never made it to the charge sheet. It is underpayments, because a commercial payer loaded last year's fee schedule and the CO-45 adjustment looked normal enough that nobody compared it to the contract. It is secondary claims that were never filed after the primary paid, sitting as patient balances that the patient does not actually owe. It is patient balances that got one statement and then went quiet because the front desk was short-staffed. None of these shows up as a denial, which is why practices that only work denials never find them.
Underpayments, and how we prove them
An underpayment is a claim that paid, so nothing in a normal billing workflow flags it. We load the fee schedule from each contract into your PM system as the expected amount. When the 835 posts, every line where the allowed amount is below expected goes on an underpayment list with the difference. Common causes: a multiple-procedure reduction applied to a code that is exempt from it, a professional component billed with modifier 26 but paid at the technical component rate, a payer applying the Medicare fee schedule when the contract says a percentage above it, or an out-of-network rate on an in-network provider whose credentialing effective date was loaded wrong. Each one is appealed with the contract page attached. Each month you get the total by payer and CPT, which is the document you want in the room at renegotiation.
How the engagement runs month to month
We begin with a free billing audit of your last 90 days and a written baseline of the five metrics above. Then we agree who does what. Some practices keep charge entry in house and hand us everything after it; others hand us the front-end eligibility work as well because their desk has turned over. Your account manager, one US-based person, owns the relationship. Daily work happens inside your EHR and PM system under our own logins. After the first 90 days the agreement runs month to month. Fees are a percentage of collections, so if collections fall our fee falls with them, and if we recover an underpayment you keep the majority of it.
What the reporting looks like
Every Monday you get a one-page weekly summary: charges, payments, adjustments, denials received and resolved, aging by bucket and payer, and any claim over a dollar threshold you set that has gone 30 days without action. Once a month we send a KPI review with the five metrics trended over the trailing twelve months, underpayments identified and recovered by payer, missed charges found through schedule reconciliation, and a write-off list where every line has a reason code. Then we get on a call for 30 to 45 minutes to go through it with you and whoever manages the practice. It arrives as a PDF you can forward to your accountant or your partners.
Who this is a fit for
Practices with 2 to 25 providers, where the revenue is large enough that a small leak is real money but the practice is not large enough to staff a full revenue cycle department. Most of our RCM clients came to us after one of three events: a practice manager or lead biller left, an A/R over 90 days number that nobody could explain, or a payer contract renegotiation that revealed the old rates were never being paid correctly. Solo providers with simple payer mixes usually do better with plain billing, and we will tell you if that is you. Hospital-owned groups with in-house revenue cycle teams are not who we serve.
What Is Included
- Eligibility and authorization checks before every visit
- Schedule-to-charge reconciliation for missed charges
- Allowed amounts compared to your contracted fee schedule
- Patient statements and payment plans on rules you approve
- Monthly KPI review of the whole cycle
| Business associate requirement | A written BAA is required before a billing company may handle PHISource: HHS, HIPAA Privacy Rule |
|---|---|
| Adjustment reason codes | Claim adjustment reason codes (CARC) such as CO-45 and CO-197 are maintained by X12Source: X12, Claim Adjustment Reason Codes |
| Medicare appeal process | Five appeal levels beginning with redetermination by the MACSource: CMS, Fee-for-Service appeals |
| Medicare timely filing limit | Claims must be received within one calendar year of the date of serviceSource: CMS, Medicare claim submission period |
Revenue Cycle Management: Common Questions
As a percentage of collections, typically 4 to 7 percent, at the higher end of that range when we take on front-end eligibility and patient collections in addition to claims. There are no software fees or setup charges. Old A/R cleanup, if you want it, is scoped and priced separately.
Billing is charge entry, claim submission, payment posting and follow-up. RCM adds eligibility verification before the visit, reconciliation of the schedule against charges, contract-level underpayment review, patient balance collections and KPI reporting on the whole cycle. If you only need claims out the door, billing is the cheaper choice.
Yes, provided you can give us the fee schedules. We load your contracted rates and compare every allowed amount on the 835 to what the contract says. Where a payer is paying short, we appeal, and we give you the pattern by payer and CPT so you can raise it at renegotiation.
We send statements on your schedule, make courtesy calls and set up payment plans within rules you approve. We do not send accounts to a collection agency without your written sign-off on each one, and we never take a percentage of a balance that was written off for hardship.
Rejection volume and first-pass rate change within the first month because same-day rework is immediate. Days in A/R and the 90-plus bucket take longer, usually one to two quarters, because old claims have to be either paid or resolved before the average comes down. We show you the baseline so the change is measurable.
No. There is a 90-day initial term so both sides can judge a full quarter of results, then the agreement runs month to month with 30 days notice. You keep your systems and your data throughout, so ending the engagement does not involve migrating anything.