Understanding the Revenue Cycle

Start with the right information

The revenue cycle starts when a patient is scheduled. Registration records who the patient is, which payer is expected to process the service, and what information may be required before care. Eligibility checks can identify an inactive plan or a different primary payer, but they do not guarantee a claim will be paid.

Follow the claim trail

After the visit, the clinical record supports charge capture. The billing team checks that the provider, location, date, diagnosis, procedure, and any authorization information are consistent. A claim can then be submitted and monitored for acceptance. Clearinghouse rejections need corrections before payer adjudication; payer denials require review of the actual adjudication reason.

Turn the findings into a process

When an EOB or ERA arrives, payments and adjustments are posted. Remaining insurance amounts require follow-up, while a properly adjudicated patient balance can be communicated according to practice policy. A/R reporting closes the loop by showing which claims remain unresolved and why.

Walk through one completed account

Use a small, representative sample before changing a full workflow. Compare what the practice expected with the information recorded in its systems and the payer's actual response. These questions make a focused review easier:

• Which payer was selected and why?
• When was the note signed and charge released?
• What happened after the first payer response?
• Who approved the final balance?

When an answer is uncertain, record the source that should resolve it. A payer portal response, signed note, enrollment confirmation, or remittance can each answer a different part of the same claim question.