Patient Access Management
Scheduling and pre-verification.
Insurance verification and eligibility checks.
Financial counselling and cost estimation.
Charge Capture
Recording services provided during patient encounters.
Assigning appropriate charges based on clinical documentation.
Capturing ancillary service charges (e.g., labs, imaging).
Medical Coding
ICD-10, CPT, and HCPCS coding for claims.
Auditing clinical documentation for coding accuracy.
Compliance checks to adhere to payer and regulatory guidelines.
Claim Submission
Claims preparation and formatting.
Electronic and manual claim submission.
Validation checks for clean claims (e.g., missing information).
Payment Posting
Posting payments to patient accounts.
Recording adjustments, write-offs, or overpayments.
Reconciling deposits with payer Explanation of Benefits (EOB).
Denial Management
Identifying and categorizing denial reasons.
Resolving coding errors or missing information.
Appealing denied claims with supporting documentation.
Accounts Receivable (AR) Management
Monitoring claim aging reports.
Following up on unpaid or underpaid claims.
Collecting balances from secondary payers and patients.
Patient Billing and Collections
Generating and sending patient bills.
Managing payment plans for patients.
Collecting outstanding balances from patients.
Revenue Integrity and Compliance
Internal audits for coding and billing compliance.
Monitoring payer contract terms and updates.
Ensuring HIPAA compliance in RCM activities.
Reporting and Analytics
Revenue and collection performance reports.
Denial trend analysis and root cause identification.
Key performance indicators (KPIs) such as Days in AR, clean claim rate, etc.
