The process of managing the financial aspects of healthcare services, from patient registration and appointment scheduling to claims processing, payment, and revenue generation.

Claim Submission:

The process of sending healthcare claims to insurance payers for reimbursement, including the preparation of billing documents and supporting documentation.

Charge Capture:

The accurate recording and reporting of the services provided to patients, ensuring that all billable activities are documented for proper reimbursement.

Denial Management:

The proactive identification, analysis, and resolution of denied insurance claims to optimize reimbursement and minimize financial losses for healthcare providers.

Clearinghouse:

A third-party entity that processes and validates healthcare claims before they are submitted to insurance payers, helping to reduce errors and improve claim acceptance rates.

Patient Registration:

The initial step in the revenue cycle, involving the collection of patient demographic information, insurance details, and consent forms before the provision of healthcare services.

Prior Authorization:

The approval process required by insurance payers before certain medical services or procedures are performed, ensuring that the proposed treatment is medically necessary and covered.

Coding and Documentation:

The assignment of standardized codes to describe medical procedures and diagnoses, crucial for accurate billing and reimbursement, and supported by comprehensive documentation.

Accounts Receivable (AR):

The total amount of money owed to a healthcare provider for services rendered but not yet collected, including outstanding insurance claims and patient payments.

Patient Responsibility:

The portion of healthcare costs that patients are responsible for paying, including copayments, deductibles, and coinsurance, which contributes to the overall revenue cycle.

Remittance Advice (ERA/EOB):

Documentation provided by insurance payers detailing the outcome of claims processing, including payments, denials, and adjustments, often transmitted electronically.

Charge Entry:

The step in the revenue cycle where charges for services are entered into the billing system, ensuring that all billable activities are accurately recorded for reimbursement.

Revenue Integrity:

The ongoing process of ensuring that healthcare services are accurately documented, coded, and billed to maximize revenue while maintaining compliance with regulations.