02 — Capability · BC-1840
Revenue Cycle
Get paid correctly and on time for the care the organization delivers, by capturing every charge, coding it accurately, submitting clean claims, overturning wrong denials, collecting patient balances fairly and negotiating payer contracts that pay what care costs. Adjudicating claims as a health plan and the general ledger are owned elsewhere.
- RCM
- Revenue Cycle Management
- Patient Financial Services
- Patient Accounting
In scope
- Chargemaster, charge capture, revenue integrity and price transparency files
- Clinical coding, clinical documentation improvement and coding audit
- Claim submission, remittance posting, denials, appeals and underpayments
- Patient statements, payment plans, self-pay collections, payer contracting and the cost report
Out of scope
- Adjudicating and paying claims as a health plan (see BC-1870.40)
- Front-end eligibility, authorization and estimates (see BC-1810)
- Revenue recognition and receivables accounting (see BC-250)
- Value-based and risk-sharing contract performance (see BC-1860.30)
Realized by · 6
- Epic · Revenue Cyclecore via BC-1840.10.20
- Oracle Health · Patient Accountingcore via BC-1840.10.20
- Oracle Health · Contract Managementstrong via BC-1840.60.20
- Oracle Health · Health Information Management and Acute Case Managementstrong via BC-1840.20.10
- Oracle Health · Oracle Health Paymentpartial via BC-1840.50.20
- MEDITECH Expanse · Revenue Cyclecore via BC-1840.30.10
Used in · 6
- Encounter-to-Cash · 01 Capture Charges via BC-1840.10
- Encounter-to-Cash · 02 Code via BC-1840.20
- Encounter-to-Cash · 03 Bill the Payer via BC-1840.30
- Encounter-to-Cash · 04 Post & Reconcile via BC-1840.30
- Encounter-to-Cash · 05 Work Denials via BC-1840.40
- Encounter-to-Cash · 06 Bill & Collect from Patient via BC-1840.50
Build it · 1
Decomposes into · 6
- BC-1840.10Revenue IntegrityRecord a correct charge for every billable service, supply and drug, priced from one maintained chargemaster, and publish standard charges as the rules require. Setting prices for products outside patient care is pricing.
- BC-1840.20Medical CodingTurn each encounter's documentation into accurate, complete diagnosis and procedure codes, supported by the record, so claims, quality data and risk scores reflect the care given. Maintaining the code sets themselves is clinical terminology.
- BC-1840.30Claim Submission & RemittanceSend each payer a clean, complete claim promptly, follow it to payment and post what each payer paid and adjusted against the account. Applying cash outside patient care is receivables accounting.
- BC-1840.40Claim Denials & AppealsRecover payment that payers wrongly deny or underpay, and remove the causes so fewer denials happen next time. Pre-service authorization denials are patient access; the payer's handling of an appeal is the health plan's own work.
- BC-1840.50Patient Billing & CollectionsBill patients clearly for what they owe after insurance, offer realistic ways to pay and collect fairly, within the organization's financial assistance policy and consumer protection rules. Collections for non-patient customers sit with billing and revenue.
- BC-1840.60Payer ContractingNegotiate payer contracts that pay fairly for the care delivered, model their effect before signing and load the terms so every claim can be checked against them. A health plan contracting with its provider network is health plan operations.