Revenue Cycle

The Healthcare Financial Management Association (HFMA) defines revenue cycle as "All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue."  In other words, it is a term that includes the entire life of a patient account from creation to payment.  Revenue cycle processes flow into and affect one another.  When processes are executed correctly, the cycle performs predictably.  However, problems early in the cycle can have significant ripple effects.  The further an error travels through the revenue cycle, the more costly revenue recovery becomes.

Rev Cycle Graphic


Charge Capture:
Documented services are manually or electronically translated into billable fees.

Claim Submission:
Billable fees are submitted to the insurance company via a universal claim form for payment.

The process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers.

Patient Collections:
Collecting patient balances, making payment arrangements.

Collection of all registration information, including eligibility, benefits and authorizations, prior to the patient's arrival for inpatient or outpatient procedures.

Collection of a comprehensive set of data elements required in establishing a Medical Record Number and satisfying regulatory, financial and clinical requirements.

Remittance Processing:
Posting or applying payments/adjustments to the appropriate accounts, including rejects.

Third Party Follow-up:
Pursue collections from insurers after the initial claim has been filed.

Utilization Review:
Evaluation of the necessity, appropriateness, and efficiency of the use of medical services and facilities, which includes regular reviews of admissions, length of stay, services performed, and referrals.