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Revenue Cycle Management

Factors affecting revenue cycle management complexity

The healthcare industry is growing rapidly. With the highest expenditures in the world, the healthcare market will reach $7.74 billion by 2028 which is showing the healthcare organization profit.

The revenue cycle is a complicated process that includes billing, claims and denial management, and simplifying revenue cycle management process to streamline overall medical billing process.

Revenue cycle management involves various management stages to clear claims and increase reimbursement. In this article, we will discuss the factors that contribute to the complexity of the revenue cycle in healthcare.

Establishing clear communication among payers, providers, patients, and your revenue cycle team is essential to successful revenue cycle management. Healthcare policies and changes are constantly changing. As a result, it is vital to stay updated for effective RCM (Revenue Cycle Management) strategies.

Efficient revenue cycle management process increases your cash flow and help you achieve your goals. There are various factors that contribute to the complexity of the revenue cycle in healthcare.

The following issues can develop if there is no fluid coordination between different units, such as the billing and coding department, data analytics department, collections department, and payer enrollment department:

  • Non-clinical insurance claim denials resulting from inaccurate patient data entry during registration.
  • Errors in medical code documentation may result in insurance payment refusal.
  • Interoperability issues in patient-provider communication due to a lack of digitization.
  • Inadequate noncompliance with the Health Insurance Portability and Accountability Act (HIPPA).
  • Medical billing and coding companies can assist in resolving these challenges by utilizing appropriate troubleshooting strategies.

The following are the lapses that healthcare facilities must avoid. These inaccuracies may have an adverse effect on the revenue management cycle.

Untrained Employees

Medical billing and coding businesses require accurate data collecting. Human error may be causing an increase in the frequency of claim denials at this stage. Incorrect ICD-10 and CPT codes for diagnoses and treatments are submitted by unskilled staff. Claim denials may occur as a result of missing patient data elements or incorrect dates entered during chart drafting. This means that the healthcare provider will have to resubmit the claims after correction, which will delay compensation.

Fragmented Administrative personnel: 

The administrative role of the front-end office is to expedite claims processing by ensuring that the patient’s name, insurance provider, and other personal facts are appropriately documented. The clinical function is responsible for the patient’s treatment and the collecting of healthcare information.

Limited Staff:

When healthcare organizations rely on existing staff for management activities, it may be difficult to handle the increasing number of patients and associated data. It is vital to hire the right people who have the right qualifications.

Inability to keep track of Medical Claims:

Healthcare practices do not place a high priority on tracking the full claims processing process. If possible claims issues are not addressed, it might result in a backlog of accounts receivable and excessive administrative costs.

Lack of Proactive attitude to Patient Payments

Medical practitioners are cautious to approach patients for their remarks as an outbound calling tactic. Payment-related information may be required by patients. Medical procedures, on the other hand, can generate higher patient payments if approached compassionately.

Ignoring the Eligibility of the Patient

Doctors should ensure that the patient is eligible. The claim will be denied if the patient’s insurance coverage is not cross-verified. Assessing patient eligibility is required to successfully manage the revenue cycle.

Inadequacy of new technology

Many healthcare facilities are still using antiquated billing systems that can’t handle enormous amounts of patient data. The failure to simplify digital operations complicates the revenue cycle. Hospitals may lack suitable infrastructure or be financially limited. When innovative technology is integrated into healthcare organizations, time, money, and effort are saved. The return on investment (ROI) improves as a result.

Elements to rev up your Reimbursement

The healthcare business is beginning to use robotic process automation and artificial intelligence to manage its revenue cycle in today’s digital environment. Automated workflows have resulted in fewer errors, higher collections, and better overall profitability. Despite these developments, some RCM processes, particularly in specialty healthcare, have gaps.

Because specialty-specific Healthcare is given, your revenue cycle procedures necessitate specialized resources with specialty-specific expertise. Because of the constant changes in legislation, RCM for specialty healthcare can be intimidating for most healthcare businesses. It can also be complicated because it necessitates attention to financial and administrative issues that dramatically influence its financial viability. Here are some techniques for dealing with them.

Prior Authorization Processes

Prior Authorization is the process through which a physician obtains payer approval before administering any treatment to a patient. Prior Authorization aids in cost containment and permits clinicians to give patients evidence-based care.

Prior authorizations are important in healthcare because doctors can create a treatment plan that meets the requirements of multiple payers. As a result, outsourcing your prior authorization process to an RCM provider with specialty-specific prior authorization regulations will help you improve your clean claim rate, decrease denials, and increase reimbursements.

One of the essential steps in medical billing is charge integrity, a patient account is engaged in this procedure, and the correct value is determined based on the medical codes and charge schedule. The charge entry procedure determines the remuneration a physician receives for services given. Aside from that, all cost accounting procedures and financial benchmarking are dependent on the practice’s capacity to get reimbursed, resulting in correct coding.

Because many specialists participate in a value-based care program or bundled payment programs, the charge entry process becomes more complicated in the specialty ecosystem. Multiple systems create varied information that aids in diagnosing and treating individuals with very complicated diseases, which adds to the complexity. As a result, healthcare companies should start moving toward data interoperability to address concerns with charge entry. Charge entry outsourcing can help you achieve charge capture accuracy of greater than 98 percent and reduce charge entry lag.

Accurate Medical Coding

Coding is one of the most challenging aspects of revenue cycle management for a specialty healthcare provider. The increasing adoption of ICD-10 criteria for specialized healthcare involves coders staying up to date on all aspects of proper procedures. A lack of understanding and poor coding could lead to revenue leakage. They can avoid payment complications caused by frequent changes in standards by outsourcing their specialist coding needs to an offshore revenue cycle management company.

A/R Management 

While managing the A/R, account receivable benchmarks for the specific specialty must be followed. A dedicated accounts receivable and denial management expert staff can keep days in A/R under 30 days. Healthcare provider are set to manage A/R and collections standard operating procedures to avoid situations where claims are not addressed due to a lack of clarity on the standards.


The Payer’s network must approve physicians to provide services to patients who are members of the Payer’s plans. The credentialing procedure verifies that a doctor meets specific criteria for providing clinical care. The Payer checks the physician’s credentials, including their education, license, and specialty accreditations. Payments to physicians who are not credentialed and enrolled may be delayed or denied. These have a negative impact on the practice’s finances.

Healthcare providers must ensure that their credentials are appropriate for their skills. Providers who have previously been credentialed should offer current information on how to get any new specialized certification. Allowing outside credentialing specialists to manage your credentialing needs will help you avoid reimbursement errors.


As healthcare providers adopt the latest clinical technologies, patient engagement tools, and reimbursement techniques, they should keep in mind that efficient billing management will determine their success. An RCM service provider with specific experience can help you improve your healthcare organization’s financial health. The quality and skills of your RCM service provider are directly linked to your financial stability.

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