Revenue Cycle Management (RCM) is the process healthcare organizations use to track and manage the financial aspects of patient care — from the moment a patient schedules an appointment to the time the provider receives full payment for services rendered.
RCM ensures that healthcare providers get paid accurately and on time by coordinating clinical, administrative, and financial functions.
Patient Registration & Eligibility Verification
Collect patient demographics and insurance information.
Verify insurance coverage and benefits to prevent denials later.
Service Documentation & Charge Capture
Providers document the visit, procedures, and diagnoses.
Charges are generated based on this documentation.
Medical Coding
Diagnoses and procedures are translated into standardized codes (e.g., ICD-10, CPT, HCPCS) for billing.
Claims Submission
Clean claims are sent to the appropriate insurance payer electronically.
Claims Adjudication
The insurance company reviews the claim, applies benefits, and determines payment or denial.
Payment Posting
Payments from insurance and patients are recorded in the billing system.
Any underpayments or denials are flagged for review.
Denial Management & Appeals
Rejected or denied claims are corrected and resubmitted.
Appeals are made if necessary to recover revenue.
Patient Billing & Collections
Patients are billed for their share (copays, coinsurance, deductibles).
Follow-ups ensure collection of outstanding balances.
Reporting & Analytics
Regular reports track key metrics like days in A/R (Accounts Receivable), denial rates, and collection rates to identify areas for improvement.
