Sample Team Structure

Role Team Responsibilities Internal Control Focus

Size

Patient Access 2-3 Registration, eligibility, pre- Separate registration from

authorization verification and pre-auth.

Coding & Charge Entry 1-2 Coding and charge entry Separate coding from charge entry.
Claims Submission & AR 1-2 Submit claims, post AR Separate claims submission and AR
posting.

Payment Posting & 1-2 Post payments, reconcile Separate payment posting from
Reconciliation accounts reconciliation.

Denials & AR Recovery 1-2 Manage denials, recover AR Document follow-ups for recovery
efforts.

Patient Billing & 1-2 Send statements, handle Separate statements from
Collections collections collections.

RCM Manager 1 Supervise, audit, and enforce Independent oversight and quality
controls assurance.
Revenue Cycle Management
Patient registration
Eligibility Verification
Pre-authorization Management
Coding
Charge Entry
Auditing /Quality Check
Claim Transmission
AR Posting
Clearing House Rejections
Payment Posting
Denials Management
AR Recovery
Patient Statement
Collections
Reporting and analytics
 Step-by-Step RCM Process: Software, Departments, and Detailed Simulation
Here’s a detailed look at each step in the updated RCM process, outlining the software typically used, the department
responsible, and a simulated "walk-through" of what you would see happening at each step.
Step 1: Patient Registration
• Software: EMR (Electronic Medical Record) System (e.g., Epic, Cerner)
• Department: Front Office or Patient Access
• Process Simulation:
o The front office staff inputs patient demographic, contact, and insurance information into the EMR system
during or prior to the patient’s visit. The system automatically checks for any missing fields and verifies that all
necessary information is collected. This step ensures the patient's data is accurate and ready for the next stages.

Step 2: Eligibility Verification

• Software: Eligibility Verification Tool integrated into EMR (e.g., Availity, Change Healthcare)
• Department: Front Office or Patient Access
• Process Simulation:
o The eligibility tool connects to insurance databases and confirms the patient’s insurance coverage. Staff
receives real-time information on the patient’s insurance status and any coverage restrictions. Alerts show up in
the system if there are issues, and front office staff may contact the patient if additional insurance information
is needed.

Step 3: Pre-Authorization Management

• Software: EMR/Practice Management System (PMS) (e.g., eClinicalWorks, Athenahealth)
• Department: Front Office or Patient Access
• Process Simulation:
o The front office staff checks if the scheduled procedures require pre-authorization. If so, they request
authorization through the system, which tracks and records approval status. The software flags any unapproved
procedures, preventing scheduling errors that might lead to denials.

Step 4: Coding
• Software: Coding Software (e.g., 3M Coding and Reimbursement System, TruCode)
• Department: Medical Coding Department
• Process Simulation:
 o Medical coders translate clinical documentation into standardized codes (ICD, CPT) using coding software.
The system helps coders by suggesting codes based on keywords in the documentation and flags any
discrepancies that need review. The coding department double-checks accuracy before moving to charge entry.

Step 5: Charge Entry

• Software: Practice Management System (PMS)
• Department: Billing Department
• Process Simulation:
o A charge entry specialist inputs the codes and corresponding charges into the PMS. The system validates the
entered information and checks for any missing data. The charge entry stage establishes the amount to be billed
for services provided.

Step 6: Auditing/Quality Check

• Software: Audit and Compliance Software (e.g., MDaudit, OptumInsight)
• Department: Billing Department or Compliance Department
• Process Simulation:
o Auditors or quality control staff review a sample of charges to verify coding accuracy and adherence to billing
guidelines. The auditing tool runs automated checks, and a report is generated for any flagged issues. The
department addresses errors to ensure clean claims are submitted.

Step 7: Claim Transmission

• Software: Clearinghouse Software (e.g., Change Healthcare, Waystar)
• Department: Billing Department
• Process Simulation:
o After a final review, the claim is transmitted electronically to the insurance provider through a clearinghouse
system. The clearinghouse verifies data fields and returns immediate feedback if any information is incorrect or
missing. The billing team corrects any issues before the claim proceeds.

Step 8: AR Posting
 • Software: Practice Management System (PMS) or Accounting Software (e.g., QuickBooks, SAP)
• Department: Accounting Department
• Process Simulation:
o The expected amount for the claim is posted to Accounts Receivable (AR) in the PMS, reflecting anticipated
revenue. The PMS or accounting software logs this as a receivable, showing a credit to income and a debit to
AR. AR records are then regularly updated based on received payments.

Step 9: Clearing House Rejections

• Software: Clearinghouse Software (same as Step 7)
• Department: Billing Department
• Process Simulation:
o Any rejected claims are flagged in the clearinghouse software. The billing department receives rejection codes
explaining the issue (e.g., incorrect patient data, missing authorization). Staff corrects these issues and
resubmits the claims through the clearinghouse.

Step 10: Payment Posting

• Software: Practice Management System (PMS) or Accounting Software
• Department: Accounting Department
• Process Simulation:
o When payments are received, staff post them in the PMS, which reduces the AR balance. Payment amounts are
verified against the insurance Explanation of Benefits (EOB), and adjustments are made based on contractual
allowances and patient responsibilities. Cash and check deposits are reconciled with daily reports.

Step 11: Denials Management

• Software: Denials Management Software (e.g., eSolutions, Waystar)
• Department: Billing Department
• Process Simulation:
 o Denials appear in the denials management system, categorized by reason. Billing staff investigates each denial,
identifies the cause, and submits any necessary corrections or appeals. The system tracks denials over time to
provide data on recurring issues and areas for improvement.

Step 12: AR Recovery

• Software: Practice Management System (PMS) with AR Tracking
• Department: Billing or Collections Department
• Process Simulation:
o AR aging reports in the PMS show outstanding balances by age. AR recovery staff follow up on older
accounts, contacting insurance or patients as necessary. The system logs all communications and follow-up
actions, providing a clear trail of recovery efforts.

Step 13: Patient Statement

• Software: PMS or Patient Billing Software (e.g., Epic MyChart, Kareo)
• Department: Billing Department
• Process Simulation:
o The PMS generates patient statements for any outstanding balances after insurance adjustments. Statements are
sent to patients via mail or email. The system records when statements are sent and flags any overdue balances
for follow-up.

Step 14: Collections

• Software: Collection Management Software (e.g., AdvancedMD, SimplePractice)
• Department: Collections Department
• Process Simulation:
o Accounts that remain unpaid after a set period move to collections. Collections software tracks patient
accounts, schedules follow-up actions, and records communications. If necessary, third-party collection
agencies are involved, and the software logs all interactions.

Step 15: Reporting and Analytics

 • Software: Business Intelligence Tools (e.g., Tableau, Power BI, or built-in PMS reporting)
• Department: Finance Department
• Process Simulation:
o The finance team pulls monthly RCM reports from the PMS or BI tools, analyzing metrics such as days in AR,
denial rates, and payment collections. Reports are reviewed with the RCM manager to make data-driven
decisions that improve efficiency and financial outcomes.

Process Simulation: Observing the Entire RCM Workflow

Imagine you’re walking through each department and observing the RCM workflow:
1. Patient Access: Staff greet patients, collect insurance details, verify coverage, and request any necessary pre-
authorizations, documenting everything in the EMR.
2. Medical Coding: Coders, in a focused environment, review patient charts and assign accurate codes, updating the
PMS to ensure the charges align with clinical services provided.
3. Billing and Claims: The billing department reviews coded charges, submits clean claims, and posts AR based on the
expected revenue from each claim.
4. Accounting: When payments come in, the accounting team verifies and posts payments, adjusting AR balances
accordingly. They review daily reconciliations of cash and check deposits against recorded amounts.
5. Denials and Collections: The billing team works through denials, resubmitting claims when possible. Meanwhile,
collections staff track overdue accounts, managing patient communication and preparing accounts for third-party
collections if necessary.
6. Finance and Reporting: Finance compiles monthly reports on key performance indicators, presenting analysis to the
CFO for insights into cash flow, operational bottlenecks, and areas of improvement in the revenue cycle.
This process emphasizes internal controls, segregation of duties, and cross-department collaboration, creating an efficient
and secure RCM process.
4o
‫أنت قلت‬:
from the above what apartments falls under RCM, AND WHAT UNDEER FINANCE ?
2/2
‫ قال‬ChatGPT:
ChatGPT
In Revenue Cycle Management (RCM), there are specific departments responsible for handling each stage of the patient’s
financial journey—from initial registration to final payment collection. Here’s how the departments typically divide
between RCM and Finance:

Departments under RCM

These departments focus on ensuring smooth patient billing, claim processing, and payment collection. They are directly
involved in the revenue generation and claims lifecycle.
1. Patient Access (Front Office):
o Handles Patient Registration, Eligibility Verification, and Pre-Authorization.
o This department is the first point of contact in the revenue cycle and ensures that patient information and
insurance details are accurate.
2. Medical Coding Department:
o Responsible for Coding.
o Medical coders translate patient care into billing codes, which are essential for insurance claims.
3. Billing Department:
o Manages Charge Entry, Claim Transmission, Clearinghouse Rejections, Denials Management, and
Patient Statements.
o This department oversees the preparation and submission of claims, addresses rejections and denials, and sends
statements to patients.
4. Collections Department:
o Involved in Collections for overdue patient balances.
o This team follows up on unpaid accounts and may coordinate with third-party collection agencies when
necessary.
5. Denials & AR Recovery Team:
o Focuses on Denials Management and AR Recovery.
o This department works on recovering denied claims, following up with insurance, and tracking outstanding
AR.
Departments under Finance
These departments handle financial controls, reporting, and cash management, ensuring that RCM activities translate into
actual revenue for the organization.
1. Accounting Department:
o Handles AR Posting and Payment Posting & Reconciliation.
o The accounting team manages the recognition of revenue, reconciles payments, and ensures cash/check
deposits align with recorded transactions.
2. Finance Department:
o Manages Reporting and Analytics.
o This department analyzes RCM performance metrics (e.g., AR days, denial rates, and collection efficiency) and
provides insights for strategic financial decisions. They also ensure accurate financial reporting and compliance
with internal controls.

Summary: RCM vs. Finance

Falls
Department RCM Activities
Under
Patient Access (Front
RCM Patient Registration, Eligibility Verification, Pre-Authorization
Office)
Medical Coding RCM Coding
Charge Entry, Claim Transmission, Clearinghouse Rejections, Denials Management,
Billing RCM
Patient Statements
Collections RCM Collections
Denials & AR Recovery RCM Denials Management, AR Recovery
Accounting Finance AR Posting, Payment Posting & Reconciliation
Finance Finance Reporting and Analytics
In essence, the RCM departments are responsible for managing the revenue cycle itself, while Finance is focused on
financial oversight, reporting, and ensuring compliance with accounting principles.
4o
‫أنت قلت‬:
IM KHALED THE CFO , AND I HAVE 3 EMPLOYEE UNDER ME THE FINANCE MANAGER AZIZ , 2 SENIOR
ACCOUNTANT AMGAD , MOHAMMED , WHAT DO YOU THINK OUR ROLES IN THIS ?
‫ قال‬ChatGPT:
ChatGPT
‫تم تحديث الذاكرة‬
Given your team structure, here’s how responsibilities in RCM and Finance could be distributed to ensure efficient
operations, compliance, and internal controls:
1. Khaled, CFO
• Primary Responsibilities:
o Strategic Oversight: As CFO, you’ll set financial goals for RCM metrics (e.g., days in AR, collection rates)
and approve high-level policies related to billing, collections, and AR management.
o Risk Management: Oversee financial risk related to billing practices and ensure compliance with internal
controls, especially around cash handling and revenue recognition.
o Financial Reporting & Analysis: Lead the final review of monthly financial statements and ensure alignment
with organizational goals, communicating findings to senior leadership.
2. Aziz, Finance Manager
• Primary Responsibilities:
o Internal Control Management: Ensure that internal controls are in place at each RCM stage. This includes
reviewing AR reconciliation, monitoring payment posting, and handling sensitive transactions.
o Performance Monitoring: Track performance metrics for billing, AR, and collections, identifying trends and
areas for improvement.
o Team Supervision: Oversee Amgad and Mohammed’s work, provide training on RCM processes, and conduct
regular reviews to ensure accuracy and compliance with protocols.
o Reporting to CFO: Compile reports and analysis for the CFO, focusing on RCM performance and identifying
any risks or areas needing intervention.
3. Amgad, Senior Accountant
• Primary Responsibilities:
 oAR Posting & Reconciliation: Handle the posting of AR based on claims submitted, ensuring accurate
revenue recognition. Perform daily reconciliations of AR with cash/check deposits, focusing on insurance
receivables.
o Payment Posting: Post incoming payments from insurance companies, verify against EOBs, and handle
adjustments for contractual allowances or patient responsibilities.
o Patient Billing & Reconciliation: Support in patient billing statements, reconciling balances, and preparing
any overdue accounts for collections.
o Reporting Support: Provide Aziz with detailed data on payment posting, AR status, and monthly aging
reports.
4. Mohammed, Senior Accountant
• Primary Responsibilities:
o Denials Management & Follow-Up: Track denied claims, work with the RCM team on resubmissions, and
document resolutions for future reference.
o AR Recovery: Focus on follow-up with insurance companies or patients on aged receivables, handling patient
communication for overdue balances.
o Collections Processing: Manage patient accounts past due, coordinating with third-party collections if
necessary.
o Metrics & Data Analysis: Assist in generating reports on denial rates, AR aging, and collections, highlighting
trends or recurring issues for Aziz.

Team Structure Summary

Team Member Primary Role Key Responsibilities
Khaled (CFO) Strategic Oversight Risk management, reporting review, policy approval
Internal Control & Team Track metrics, oversee Amgad & Mohammed, report to
Aziz (Finance Manager)
Supervision CFO
Amgad (Sr. Accountant) AR & Payment Posting AR posting, payment reconciliation, support patient billing
Mohammed (Sr. Denials management, AR recovery, manage collections
Denials & Collections
Accountant) processes
This division enables clear accountability across the RCM and Finance functions, ensuring efficient, compliant operations
and accurate reporting.