Revenue Cycle Management (RCM)

Every dollar of revenue travels through RCM. From the moment a provider signs off on an encounter and charges auto-capture, through AI-powered claim scrubbing, electronic 837P submission, 835/ERA auto-posting, denial triage with pre-drafted appeal letters, to the AR aging dashboard that tells you where the money is stuck — RCM closes the loop from clinical encounter to cash in the bank. The target is a ≥98% first-pass clean-claim rate and ≤30-day median days in AR.

Key Capabilities

AI Claim Scrubbing

Before a claim leaves the platform, it passes through a payer-specific rules library with 10,000+ edits — NCCI pair violations, MUE limits, LCD/NCD coverage determinations, and custom payer modifiers. Conflicts are flagged with severity: errors block submission; warnings can be overridden with a documented reason by a coder (level 50+). The scrubbing engine runs in ≤2 seconds per claim. The rules library is updated weekly so the practice stays ahead of payer policy changes.

Denial Root-Cause Tagging

Denied claims don't sit in an undifferentiated queue. The AI triage engine categorizes every denial into one of six root categories — Eligibility, Authorization, Coding, Timely Filing, Coordination of Benefits, or Medical Necessity — and assigns a machine-readable root-cause tag (missing_modifier, no_auth_on_file, incorrect_dx, etc.). The tag drives automatic routing to the correct work queue and surfaces the optimal next action in the Task Management module.

Pre-Drafted Appeal Letters

For appealable denials, the system generates an appeal letter pre-populated with the denial code, claim data, clinical documentation excerpts, and regulatory citations — CMS IOM references, state insurance law, and payer contract language. The billing manager reviews and submits; the denial status transitions from NotAppealed to AppealDraft to AppealSubmitted. Deadline tracking ensures no appeal window is missed, with SLA escalation via Task Management when the deadline approaches.

ERA Auto-Posting

Inbound 835/ERA remittances are auto-matched to open claims and posted without manual intervention. Contractual adjustments are calculated automatically from the allowed amount vs. billed amount. Patient responsibility (copay, coinsurance, deductible) is split and routed to patient billing. Denials are categorized at posting and routed to the denial workflow. Target: ≥95% of ERA files auto-posted without human touch.

AR Aging Dashboard

A real-time dashboard surfaces days in AR, clean-claim rate, denial rate, first-pass resolution rate, collection rate, and net collection rate — broken into aging buckets (0–30, 31–60, 61–90, 91–120, 120+ days). Payer-level and provider-level drill-down reveals where revenue is leaking. Configurable alert thresholds notify the billing manager when key metrics drift outside target ranges.

Recurring-Denial Pattern Detection

Root-cause analytics surface systemic denial patterns by category, payer, provider, and coder. If a single payer is denying 99213 + 25 modifier claims at twice the average rate, the dashboard flags it. If a specific coder's claims generate recurring NCCI violations, the system surfaces a training recommendation. This turns denial rework into root-cause prevention.

Clean-Claim Rate Tracking

The first-pass clean-claim rate is the north-star metric. It is tracked in real time on the AR aging dashboard and decomposed by payer, provider, and claim type. The target is ≥98% — each denied claim costs rework, and 98%+ first-pass is the industry benchmark for a mature scrubbing pipeline. The rate is computed from Claim.StatusString transitions: claims that move directly from Submitted to Accepted or Paid without entering Rejected or Denied count as clean.

Persona Connections

• RCM / Priya — Primary user. Owns the revenue cycle end-to-end: scrubbing, submission, posting, denials, collections. Lives in the denial-triage dashboard and the days-in-AR report. Needs claim-status visibility without logging into a separate clearinghouse portal. Drives the ≥98% clean-claim target.
• Doctor — Signs off on charge capture at encounter close. Reviews AI coding suggestions and modifier warnings at the point of sign-off. Sees MIPS quality scores on the dashboard. Benefits most from the elimination of "we lost the charge" and "the claim was denied for a coding error you could have caught."
• Practice Manager — Monitors financial dashboards: AR aging, net collection rate, clean-claim rate, denial rate by payer. Reviews the root-cause analytics that surface systemic issues. Approves bad-debt write-offs and overrides SLA escalations.

Technical Highlights

• X12 transaction suite. RCM processes 837P (professional claim submission), 835/ERA (remittance advice), 999 (functional acknowledgment), and 277CA (claim status inquiry/response). 276/277 real-time status queries surface payer acknowledgment, acceptance, or rejection without leaving the platform. Secondary and tertiary claims are auto-generated when the primary payer adjudicates, with COB-adjusted amounts.
• Claim status tracking. The Claim entity tracks status through Draft → Scrubbed → Submitted → Accepted → Rejected → Denied → Paid → PartiallyPaid → WrittenOff → Voided. The ClearinghouseTrackingIdString correlates the claim to the clearinghouse's tracking ID for 276/277 status queries. Submission timestamps and acknowledgment receipts are captured in real time.
• ERA reconciliation engine. Inbound 835 files are parsed and auto-matched to open claims by claim number and patient. Payment rows are created with PaymentMethod = "ERA" and the trace number populated. Claim-level and line-level financials (allowed, paid, adjustment, patient responsibility) are updated from the ERA. Denials are routed to the denial workflow at posting time. Files with up to 500 claim-level remittances are parsed and posted in ≤30 seconds.
• Denial taxonomy. The AI triage engine maps every denial to one of six categories (Eligibility, Authorization, Coding, Timely Filing, COB, Medical Necessity) and assigns a root-cause tag. The Denial.DenialCategoryString and Denial.RootCauseString fields are populated automatically. The denial taxonomy drives routing, escalation, and the root-cause analytics dashboard. AI categorization accuracy target: ≥85% against manual reviewer consensus.
• Org-scoped isolation. All five RCM noun-apps (Claim, ClaimLine, Payment, Denial, PatientStatement) are org-scoped with OrganizationID partition-key isolation. Practice A never sees Practice B's billing data. Clinical facts referenced by FK (Patient, Encounter, Provider) are global and cross the org boundary.

Revenue Flow Pipeline

The spine of this module transforms a signed clinical encounter into cash in the bank — with every step auditable, every denial triaged, and every payment reconciled:

1. Provider signs encounter → charges auto-capture from procedures, immunizations, POC labs.
2. AI coding engine proposes CPT/ICD-10 pairs; modifier intelligence flags conflicts.
3. Claim scrubber validates against 10K+ payer-specific rules → clean claim generated.
4. 837P submitted via clearinghouse (Waystar primary, Availity secondary) → 999 acknowledgment.
5. 276/277 status query surfaces payer decision → claim accepted or denied.
6. 835/ERA auto-posted → contractual adjustment calculated, patient responsibility split.
7. Denied claims → AI triage → root-cause tag → work queue → appeal letter → deadline tracking.
8. Patient statements via InstaMed → online bill pay → payment plans → collections routing.

Delivery Phases

Success Metrics

• First-pass clean-claim rate: ≥98% — each denied claim costs rework; 98%+ first-pass is the industry benchmark.
• Days in AR: ≤30 days median — practices above 45 days are typically understaffed or under-automated.
• Denial rate: ≤5% of submitted claims — best-in-class deny <5%; above 10% signals systemic gaps.
• Denial first-pass resolution rate: ≥65% resolved on first appeal — high first-appeal success means the triage engine is categorizing accurately.
• ERA auto-posting rate: ≥95% — manual posting is the largest billing-labor sink.
• Net collection rate: ≥96% — below 90% signals write-offs or collection gaps.
• Charge capture completeness: ≥99% of encounter-close events generate a charge within 24 hours.

Module Dependencies

• Upstream — Clinical Documentation generates the encounter that RCM auto-captures charges from. Coding / CDS authors the AI coding suggestions and scrubbing rules that RCM invokes in the claim pipeline.
• Lateral — Eligibility confirms active coverage at charge capture and feeds COB data for secondary/tertiary claims. Task Management surfaces denial work queues, appeal deadlines, and escalation alerts.
• Downstream — Payer Optimization consumes denial data for the ROI dashboard and feeds coding suggestions back into the charge-capture flow. Patient Portal renders statements and processes online bill pay.

Try This in the Demo

• RCM — Full dashboard →
• RCM — Claims screen →
• RCM — Denial triage screen →