What is the RCM workflow?

Revenue Cycle Management workflow or RCM workflow refers to the methodical and concerted set of steps and processes required for managing the financial aspects of healthcare services. From patient registration to the collection of final payments, the healthcare revenue cycle management workflow includes the end-to-end services that go into making a healthcare business successful.

Using the RCM workflow is important to maintain financial stability, ensuring healthcare providers receive proper reimbursement for the services they deliver. The RCM workflow involves several stages. Each stage comes with its own set of responsibilities and activities. To ensure overall success, all these activities must work together like clockwork.

Why is RCM important

It’s fair to say RCM is crucial to healthcare service providers. Along with ensuring financial stability, RCM impacts many aspects of the business. Everything from optimizing revenue, controlling costs, improving cash flow and meeting financial obligations falls under the purview of RCM workflow.

In addition to the accounts department, RCM’s impact on patient satisfaction through transparent billing, clear communication and payment assistance cannot be underestimated. It also ensures compliance with regulations, minimizes risks and supports overall organizational sustainability.

The Revenue Cycle: Where it all begins

Providing quality services is top priority for any industry and healthcare is no different. Focusing on core work is not enough, health care providers need to pay attention to the financial aspects of their business. This is where the revenue cycle steps come into play. Think of it as a well-oiled machine involving various parts – each with a unique role that ensures the seamless delivery of operations and financial stability. Failure in one part can have ramifications elsewhere, with varying degrees of seriousness.

Revenue Cycle Steps

Healthcare practices are different and have their own distinct workflows. However, a number of steps are the same across providers. Broadly speaking, the revenue cycle management workflow can be broken into 8 steps.

Step 1: Patient Registration and Check-In

It all begins with a patient arriving at the healthcare facility. This is the time when patient information is collected, including their personal details, insurance information, and depending on the treatment, any necessary consents. A smooth and comprehensive process will ensure healthcare providers have collected important information and details. Any oversight here can have a domino effect and lead to delays or disappointment.

Step 2: Insurance Verification

Properly registering patients and verifying their insurance coverage ensures payment for services is received in time and without additional inputs. Here, healthcare providers should focus on working closely with insurance providers, checking coverage limits, benefits and whether there are any pre-authorization requirements. Not only will this prevent any surprises that could cause delays, but also ensures patients have a transparent experience

Step 3: Coding and Charge Capture

Like everywhere else, tech and coding are playing a greater role in healthcare, even at the backed. A skilled team of coders will be able to translate medical procedures, diagnoses, and treatments into industry standard codes. Codes capture the entire journey of a patient, and contribute to creating a good experience at the final touch point – the billing processes. Healthcare providers should work with a team of specialized coders to avoid lapses.

Step 4: Claims Submission

The next step after completing the coding is submitting claims to the insurance company.  With everything having moved to computers and electronics, healthcare providers can submit claims quickly and error free. In addition to accurate submissions that help in smooth administration, this also ensures the reimbursement process is quick and easy. With claims submitted in a timely and orderly manner, providers can focus on providing their patients the right care. 

Step 5: Claims Adjudication

The submitted claims are reviewed by insurance companies for accuracy and validity. Known as claims adjudication, insurance companies will verify the codes, matching them with the services provided. The amount to be reimbursed will be calculated and disbursed. Claims adjudication can be a lengthy and time consuming affair. Healthcare providers can create processes for regular follow ups on outstanding claims, ensuring they are processed without delay.

Step 6: Payment Posting and Reconciliation

After processing accurate claims, insurance companies release payments due to providers. These payments aren’t always instant and there can be a significant delay between the submission of claims and actual release of payments. Healthcare providers need to keep track of this process and post payments against outstanding balances as soon as they are made. This is necessary to ensure accurate accounting and reconciliation. Further, it helps keep track of payments, outstanding balances, and denials – all necessary elements that maintain financial clarity.

Step 7: Denial Management and Appeals

An inevitable truth of the healthcare industry is that sometimes, despite best efforts, claims will be denied. From errors to the need for additional documents, there are several reasons for a claim to be denied. But denied claims shouldn’t simply be accepted – providers should investigate why the claim was denied, the reasons behind it, and if there’s any opportunity to appeal denied claims. Such investigations can also help healthcare providers identify gaps in their own processes and rectify them.

Step 8: Patient Payments and Collections

Last but not the least, healthcare providers need to work closely with patients about their financial responsibilities. This is often the final interaction between the patient and provider, and any lapse here can overshadow all the good work done until now. A clear process with transparent billing and multiple payment options go a long way in delivering a good experience. Top of the line customer service will help make the financial aspect of healthcare smooth and stress free. Healthcare providers who readily listen to patients, answer questions and provide the necessary support with payment plans will see more satisfied customers.


And those are the various steps of the revenue cycle management workflow.

Its imperative healthcare providers understand the RCM workflow is not only about numbers and payments. It’s about providing exceptional care, without compromising on financial stability. Building relationships with patients helps increase trust and ensures they feel comfortable and confident throughout the experience.

Delivering healthcare services is the core work of healthcare providers. But without smooth, convenient and transparent financial processes, providers run the risk of damaging relations with their patients. By outsourcing these processes, healthcare providers can focus on what they do best – look after the health and well being of their patients.

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