Last updated on Thursday, 27, November, 2025

Healthcare providers can be paid for their services quickly and effectively due to revenue cycle management (RCM), a crucial financial process. Claim payments that are lost or delayed might have a domino effect on the standard of care. Revenue cycle management guarantees that healthcare providers have the means to meet the standards set by commercial and public payers for quality treatment and to deliver it. In order to manage the healthcare insurance cycle, these resources include personnel, funds, policies and procedures, and electronic health record (EHR) systems.

Providers face many challenges when they lack resources, one of which is having insufficient administrative staff to manage both new and returning patients. The practice makes less money when patient volumes are lower. In addition, fewer personnel are overseeing safety protocols and office conditions due to a shortage of administrative resources, which may result in non-compliance problems. Quality care is the foundation of a successful practice, and an organized revenue cycle is essential to both.

Steps in the Revenue Cycle

Staff members and healthcare professionals must adhere to a standardized 10-step cycle in order to manage the healthcare insurance model. There are two parts to the process for revenue cycle management: front end and back end. 

• All of the stages that come before the claim is submitted make up the front end of the revenue cycle. 
• Steps after the claim is submitted are included in the back end.

10 Steps of the Revenue Cycle Management Workflow

1-Insurance Eligibility and Patient Registration

Pre-registration, registration, and scheduling are all included for new or returning patients. Pre-registration comprises eligibility verification and the collection of patient demographic data, including insurance information.

Challenges

• Accuracy of data entry 
• Finding the right payers 
• Coordinating the advantages of extra patient regulations 

2-Meeting, Coding, and Capturing Charge

The physician records the patient’s visit in the electronic health record (EHR) when the patient shows up for appointments, also known as encounters. The patient’s medical history, encounter notes, diagnosis codes, information about follow-up, orders, prescriptions, tests, and assessments are all included in the paperwork.

Based on physician documentation, the medical coding team records diagnosis (DX) codes, healthcare common procedure coding system (HCPCS), and current procedural terminology (CPT). A modifier based on the payer and procedure type (CPT code) may also be included by the coder. Complying with payer criteria and claim requirements is crucial in order to guarantee payment for the provided service or interaction.

Challenges

• Inadequate recording of the interaction 
• Patient policy ignorance 
• Excessive medical expenses 
• Identifying the appropriate CPT or HCPCS in accordance with provider specifications

3-Submission and Scrubbing of Claims

The billing staff completes a CMS-1500/UB-04 form or inputs the charges for the claim into a medical billing system. Next, the group drafts the claim in the EHR of the provider and submits it to the clearinghouse either electronically or on paper (the insurance company may be a government agency or a private payer). The payer receives the claim from the clearinghouse, and it can be rejected. The billing team may determine and address the underlying reason for the clearinghouse’s denial of the claim. The team can reprocess the claim and deliver it to the payer after determining the cause.

Challenges

• Recognizing quickly payer and clearinghouse denials

4-Query on Claim Status

The back-end staff, which consists of accounts receivable and billing professionals, will monitor the claim status and keep note of the date the practice filed the claim. A minimum follow-up should occur once every thirty days until the claim is reimbursed by the payer. The practice might need to step up how frequently it follows up on claims in some circumstances.

Challenge

• To make sure the medical billing team addresses claim denials, it is essential to determine how long a payer takes to process claims. 
• It’s crucial to properly note the claim and provide as much information as necessary. 
• It takes less time to follow up on claims if the team takes as many detailed notes as they can.

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5-Advice on Remittances

Claims are received by the payer, who either pays them back or rejects them. The payer transmits additional data, including copayments, deductibles, and reimbursements, along with specifics about the amount billed and/or denied.

Challenge

• Underestimating the explanation of benefits (EOB) or remittance advice (RA) and recognizing problems and remedies

6-Refusals and Appeal

In order to address denials, the billing team will determine the underlying reason and submit an adjusted claim, reconsideration, or appeal. The billing department will then inquire about the status of the denial. The insurer will make payment if it reverses its decision to deny the claim. The appeals procedure is restarted if the payer continues to reject the claim. In the event that the payer does not modify its decision following this process, the healthcare provider may elect to deduct the claim from its total losses.

Challenge

• The majority of payers handle claims in 7–21 days
• Medicare claims: within 7 to 14 days
• Commercial claims: between 14 and 21 days
• Choosing whether to write off or recover a claim
• Figuring out whether the codes billed are supported by the medical records or if a different code is better appropriate for the interaction

7-Posting of Payments

The medical billing software will be updated by the billing staff with the payers’ reimbursement. This gives a quick overview of healthcare providers’ financial situation.

Challenge

• Effectively entering payments and detecting inconsistencies in payments.

8-Statements from Patients

Medical bills are generated and distributed to the patient following data entry into the medical billing software. Using current billing tools, this step can be automated. All costs that are considered the patient’s responsibility are included in the medical bill.

Take into account the patient’s preferred method of communication when sending statements: text, email, or print. Choosing the appropriate channel can enhance patient financial participation and raise the possibility that they will promptly pay their bills.

Challenge

• The administrative expense of mailing or electronically delivering patient statements 
• Not all patients pay their fees after getting a statement. 
• Patients call the provider’s office to ask for an explanation since they are unsure of the purpose of the statement.

9-Monitoring Patients

When they receive a statement, many patients are hesitant or unable to pay the remaining amount on their medical expenses. The main causes of this include unclear benefits, rejected claims, exorbitant service fees, or other monetary difficulties.

The healthcare provider is required to get in touch with the patient and collect any unpaid balances when they don’t make payments.

Challenges

• Insufficient funding sources to help the patient pay off their bills 
• Healthcare professionals lack the necessary personnel and training to act as debt collectors.

10-Payments

You will be paid for your services after you have finished processing insurance reimbursement and following up with patients. 

Finally

Health companies should take up revenue cycle management to ensure they maximize cash and revenues. Only those health organizations that manage their revenue cycle effectively are well placed to navigate the difficult financial waters and meet their financial objectives. Good revenue cycle management is essential to a strong, long-lasting healthcare company.

FAQs

How does revenue cycle management work?

The procedure used by healthcare businesses to keep track of patient interactions, submit claims to payers, and obtain reimbursement is known as revenue cycle management, or RCM. The fundamental steps of the RCM workflow are ten.

Why is it crucial to manage the revenue cycle?

For healthcare professionals to receive paid in full and on schedule for the services they perform, effective RCM is essential. It supports healthy cash flow, reduces denials, and maximizes reimbursement.

Who is in charge of every steps?

The various RCM phases are usually carried out by different roles and departments within the healthcare business. Examples of these roles and departments include front desk staff, coding specialists, billers, and revenue cycle managers.