Successful Healthcare Revenue Cycle Management

Successful Healthcare Revenue Cycle Management

A successful healthcare revenue cycle management system can help hospitals streamline administrative and clinical tasks. 

In simple terms, healthcare organizations must stay in the black and maintain profitability to succeed at healthcare revenue cycle management. Let’s show you how to maximize the revenue cycle and ensure paid claims quickly.

“If you’re bringing in a certain amount of revenue, you can’t have expenses that exceed that revenue. It seems very basic, but people don’t look at it that way,” said Neerav Jadeja, Administrator at Paradise Valley Hospital.

“Healthcare is constantly changing, so maintaining financial stability is challenging. We are always looking to ensure we reimburse for the services we provide. And to improve our communication with our payers on claims to ensure financial stability and balance our large charitable care contributions.”

Successful healthcare revenue cycle management focuses on front-end tasks to help claims move along. Many errors occur in the first stages of a patient’s account. These issues can carry through the revenue cycle to disrupt claims reimbursement.

Providers must verify insurance eligibility during pre-registration to ensure that insurance companies reimburse the healthcare organization for medical services provided. According to a ClaimRemedi survey, the top reason for claim denials is eligibility issues.

“Competitive and transparent pricing of services, high-quality clinical outcomes, and effective billing and collection process is becoming more important than ever,” maintained Derek Bang, CPA, CGMA, Chief Innovation Officer at Crowe Horwath LLP“The front-end of the revenue cycle must be diligent with determining Medicaid eligibility and assist uninsured patients in understanding their coverage options with the insurance exchanges.”

Healthcare organizations should also effectively manage claim denials and develop procedures for quickly resolving claims reimbursement issues. From improper ICD-10 coding to a missing signature on a patient’s charts, it’s easy to deny a claim based on technical or clinical problems.

Claims denials have also been on the rise as federal agencies combat healthcare fraud, waste, and abuse. 

To resolve claim denials, the American Hospital Association found that 43 percent of hospitals have spent more than $10,000 in the first quarter of 2016 to manage claim denials, and 26 percent have invested over $26,000.

We can avoid many claim denials by training staff on completing upfront tasks, such as using billing forms and talking to the patient. Especially about medical costs and investing in revenue cycle software that automates coding and insurance verification. Healthcare organizations should also regularly track claims and investigate causes of denials.

Many providers also use big data analytics and health IT solutions to run successful healthcare revenue cycle management programs. With more payments tied to value-based care models, healthcare organizations must report on numerous measures for quality care, patient satisfaction, robust health IT use, and healthcare costs to receive total reimbursement rates from payers.

Big data analytics has helped healthcare organizations manage large volumes of information and inform employees of revenue cycle management goals, primarily through dashboards and alerts. Analytics can also help to predict claim results by tracking its lifecycle.


Health IT and EHR systems have helped streamline and provide more accuracy to healthcare revenue cycle management strategies. Many organizations use technology to track claims throughout their lifecycles, collect payments, and address claim denials. Ultimately, these technologies facilitate a steady stream of revenue.

Approximately 4,201 hospitals have already invested in healthcare revenue cycle management technologies. Which have been especially useful for handling traditional fee-for-service claims and value-based reimbursement arrangements. The industry transitions to new payment models.

We expect Healthcare revenue cycle management solutions to become even more popular. Investments in healthcare revenue cycle management software and we predict that services will grow by 15.51 percent over the next couple of years. We project that the total spent on revenue cycle management solutions worldwide to reach $7.09 billion by 2020.

Many providers have benefitted from automating common healthcare revenue cycle management issues, such as payer-improving payer-provider communications, recommending appropriate ICD-10 codes, monitoring medical billing processes, and even scheduling patient appointments.

While these technologies can be expensive, some providers choose to consolidate with other healthcare organizations. To invest in healthcare revenue cycle management solutions or outsource some revenue cycle management functions, such as collections.

“Generally speaking, to strengthen the revenue cycle management, embracing technology within the revenue cycle is key,” stated Chad Sandefur, Director, and Healthcare Analyst at Arte. “Having the platforms to facilitate provider-payer interactions are integral seamlessly. In many cases, it’s mostly about bad debt avoidance. With that in mind, there are a few specific points. Some of these specific five might not be the most glamourous. Still, certainly, on the element of embracing technology, they are critical.”

Healthcare revenue cycle management continues to evolve and keep pace with rapid changes to the healthcare ecosystem, such as value-based care. Healthcare professionals should always be aware of how their revenue cycle provides appropriate supervision and receive proper reimbursement.


With ever-changing healthcare regulations and new reimbursement models, it can be difficult for healthcare organizations to maintain stable healthcare revenue cycle management policies.

One of the top revenue cycle management challenges for healthcare organizations is collecting patient payments at or before point-of-service. While collecting payments before a patient leaves the office can save time and effort with collections, most providers say that it is an arduous task, as reported by an Availity Research study.

“Internally, all healthcare facilities should have an education component. Hospitals are losing money.”

Collecting at point-of-service has become more complicated since many patients cannot afford to pay medical bills upfront, and many deductibles have risen. Healthcare organizations struggle with ensuring that debts are collected while not pressuring the patients so much that they seek care at other facilities.

It’s possible to lose revenue if providers cannot identify where issues originated and resolve errors quickly. Providers can usually receive automated alerts that address why payers routinely deny claims for specific procedures or codes.

Healthcare organizations should invest in regular employee education programs that promote proper coding techniques, comprehensive chart documentation, and financial policy reminders. These training sessions have links to a better return on investment, such as lowering turnover rates and reducing medical errors.