Revenue cycle management is confusing for a reason. The paperwork, the money and the record travel separately, through different parties, at different speeds. This is one ordinary claim, followed the whole way, with every party that touches it named.
Drag the bar, click any stop, or use the arrow keys. The map lights the parties involved in each step and draws what moves between them. Periwinkle is information, mint is money. The figures are illustrative; the sequence is not.
A practice does not lose track of a claim because anyone is careless. It loses track because one event splits into three, and the three arrive at different addresses on different days.
The claim goes to a clearinghouse, which checks the envelope and routes it, then to the carrier, which is the only party that can say yes or no. The explanation comes back the same way, weeks later.
Payment leaves the carrier through a payment processor and lands at the bank on its own schedule, often days apart from the explanation of what it was for. Sometimes it arrives as a card, with a fee attached.
The ledger cannot close until what was billed, what was explained and what was deposited all agree. Until then the claim is open, and nobody can say with confidence whether the practice was paid correctly.
Every one of these has a boring answer, and every one of them costs a practice hours on the phone. Each answer points back at the step in the map where it happens.
Because the number that governs everything is the allowed amount, and it is often set by a network the carrier rents rather than by the carrier itself. A practice can be paid at a rate it never negotiated with the plan it is billing, which is why the payment so often fails to match the contract on the shelf.
A predetermination is an estimate, not a promise. It reflects eligibility and remaining benefits on the day it was processed. The real claim is still read against frequency limits, missing-tooth clauses, waiting periods, other coverage, whatever is left of the annual maximum, and whether the patient was still eligible on the day of the visit.
Both, and they are simply on different roads. The remittance advice travels as paperwork and the payment travels as money, through different parties, on different schedules. Until they are matched, the deposit in the bank is a number nobody can yet assign to a patient.
At some carriers a virtual card is the default rather than the exception, and it carries a card processing fee of roughly two to three percent, taken out of money already earned. Direct deposit usually costs nothing, but it has to be enrolled separately from the paperwork, with its own wait of thirty to sixty days.
Because a claim closes on a three-way match, not on a deposit. What was billed, what was explained and what was deposited all have to agree, and the write-off has to be posted as a write-off rather than quietly absorbed. That is the step where underpayment is either caught or lost for good.
Most of the delay above belongs to the industry, not to any one product, and we would rather say so than pretend otherwise. What software can honestly change is how much of it a practice has to feel, and how much of it goes unnoticed.
The eight jobs of the revenue cycle, run on one record, with the write-off posted where it can be seen rather than absorbed.
Read more →Contract VarianceThe gap between the rate on the shelf and the rate actually paid, per payer and per code, out of your own history rather than an industry average.
Read more →Vella ConnectA read-only look at your own claims and remittances, so the first conversation is about your numbers and not a demonstration.
Read more →Nobody in this chain is hiding the ball. It is just that no one party has ever been able to see the whole of it at once, and the practice is the one left holding the difference.
The scalable operating system that actually improves financial performance on its own.