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Revenue Cycle Process in Healthcare: 7 Key Steps

May 24, 2023 6:50:30 PM / by Altruis


If your healthcare organization’s revenue isn’t as strong as it should be, it’s time to review your review cycle process. For maximum revenue, every stage must be as efficient and effective as possible. Below is a summary of the 7 key steps in the process, including how to optimize each step.

#1 Patient and Provider Pre-verification

The first step in managing the clinical revenue cycle is pre-verifying patients to establish coverage eligibility. Do they have Medicare/Medicaid or other insurance? What is their coverage, including their deductible, co-insurance, or co-payment? Will a referral be required?

Doctor and provider information should also be pre-verified as early as possible in this process. Ideally, this should occur before the patient ever sets foot in your facility for an appointment as part of your provider credentialing plan

Gathering this information up front reduces claims rejections and prevents wasted work. Luckily, this step is no longer as tedious as it used to be due to automation and the digitization of the revenue cycle process in healthcare.

#2 Registration and Accuracy Check

The next step is verifying the accuracy of patient information to prevent errors that could slow down the process. Double-check the patient’s basic information like their contact phone number, date of birth, address, and so forth. Ensure they’ve received copies of your policies, including disclosures and your no-show policy.

Verify coverage details and information for referring doctors and specialists. The more information you can verify at this stage, the more likely you will be to maximize your payments in the later stages of the process.

#3 Charge Capture

The charge capture step involves converting claim codes into charges and encouraging payments to flow into the billing side of your operation as quickly and revenue-positively as possible. In the old-fashioned setup, a billing clerk manually entered information and kept track of your A/R billing along the way.

In the modern paradigm, this process is handled digitally and your system highlights missing information, late payments, miscoded charges, and other key factors impacting getting paid for your services. Ensure your digital platform is fully supported with human oversight to identify bottlenecks and resolve payment processing issues.

#4 Claims Submission

The claims submission stage ensures diagnostic codes match expectations from payors like Medicaid, Medicare, and insurance providers. This step includes claims scrubbing, which ensures clean, appropriately-coded claims will pass in and out of your organization efficiently.

One of the biggest obstacles to effective claims submission is misunderstanding rejections vs. denials and handling resubmissions inappropriately. Ensure your staff is fully trained on the distinction or outsource this aspect of your operations to facilitate maximum claims payment.

#5 The Remittance Process

Remittance is initiated after claim information goes out to the appropriate parties. Patients should receive explanation of benefits (EOB) forms showing what they were charged and what amount is being covered by another party, like Medicare/Medicaid or insurance. 

Appeals for coverage can still occur during this process, yet they are often missed and ignored by busy healthcare practices. Although some write-offs are inevitable, many can be avoided with proper remittance management. Ensure your healthcare organization is routinely monitoring the remittance process to support routine appeals.

#6 Follow-up on Denials and Resubmissions

Follow-up is often the missing piece in the revenue puzzle. Low revenue can be a byproduct of infrequent or nonexistent follow-up. If nobody is in charge of tracking denials and resubmissions, these valuable claims will likely languish unpaid.

Run follow-up reports showing claims stalled in the process, then track down what’s holding up successful payments. Look into anything suspicious and be diligent about investigating large and small pools of unclaimed revenue. Ask questions like the following. 

  • Why is it taking us so long to get paid?
  • Who is assigned to follow up on these claims?
  • Are all claims being investigated and resubmitted as expected?
  • Where do we have opportunities to streamline this process for better revenue?

#7 Collections and Revenue Recapture

Finally, the process enters the patient collections period. When your healthcare organization follows the best practices of earlier steps, this stage should be smooth and should result in the highest possible captured revenue.

Ideally, all claims would be resolved fully within 30 days. In the real world, it often takes 60 to 90 days before payment occurs and occasionally, a bill collector must be brought in to follow up on long overdue claims. Cleaning up your collections and tightening the billing cycle in medical billing is the best route to optimizing the entire process for the highest revenue.

How Does Altruis Help With the Revenue Cycle Process in Healthcare?

Altruis adds speed, clarity, accuracy, and peace of mind to the process. Instead of allowing your staff to be bogged down by billing issues, Altruis implements the latest revenue cycle management techniques to maximize revenue and minimize hassles in healthcare.

From the earliest stages of the process until you get paid and beyond, Altruis streamlines every step to be as effective as possible. We handle tasks like verification, registration, patient intake, claims submission, claims monitoring, charge capture, coding review, payment posting, denial management, appeals, collections, and more.

Altruis also goes beyond the basics of revenue cycle management to assist you with the analytical side of the corporate revenue cycle. Ask us about conducting a review of your key performance indicators (KPIs), setting benchmark targets, improving your system access and setup, training your staff, and implementing strategies to boost your return on investment (ROI).

Schedule a call with us to learn more about the benefits of revenue cycle management with Altruis. We’re your partner in optimizing healthcare for outstanding revenue.


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Topics: Revenue Cycle Management, billing cycle in medical billing, corporate revenue cycle, clinical revenue cycle


Written by Altruis

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