Front-End Revenue Cycle
Gathering initial demographic and contact information when an appointment is made.
Patient Scheduling & Pre-registration
Documenting all services, procedures, and supplies provided to the patient during the encounter
Charge Capture
Claim scrubbing
Claims Generation & Submission
DSO
Days Sale Outstanding
Confirming active insurance coverage, benefits, co-pays, deductibles, and policy limitations before services are rendered.
Insurance Verification & Eligibility Checks
Reviewing medical records to ensure that documentation is complete, accurate, and reflects the full severity of the patient's condition and the services provided.
Clinical Documentation Improvement (CDI)
Insurance company reviews the claim and determines what they will pay based on the patient's policy and their own rules.
Claims Adjudication
ADD
Average Days Delinquent
Obtaining necessary approvals from insurance companies for specific procedures or treatments before they are performed.
Prior Authorization
Translating the documented diagnoses, procedures, and services into standardized codes (e.g., ICD-10 for diagnoses, CPT for procedures, HCPCS for supplies) that payers can process.
Medical Coding
Recording payments received from insurance companies and patients to individual patient accounts.
Payment Posting
DFNB
Days Final Not Billed
Informing patients of their financial responsibility (co-pays, deductibles, out-of-pocket costs) and collecting payments at the point of service to improve cash flow and reduce bad debt.
Financial Counseling
Reviewing the appropriateness and medical necessity of care, often involving communication with payers to ensure services meet coverage criteria and are delivered in the most appropriate setting
Utilization Management
Proactively monitoring outstanding claims, identifying unpaid or underpaid claims, and following up with payers to secure payment.
(A/R) Follow-up
CEI
Collection Effectiveness Index
Ensuring that the services requested are medically necessary and covered by the patient's insurance.
Medical Necessity Checks
Pre-bill regularly reviewing coded claims for accuracy and compliance with official coding guidelines, payer rules, and regulatory requirements to prevent errors and ensure proper reimbursement.
Quality Audits/Compliance
Generating and sending statements to patients for their outstanding balances after insurance payments have been applied, and managing patient collections
Patient Billing & Collections
DDO
Days Deduction Outstanding