Revenue Cycle Anatomy
What Happens at Each Stage and Where Errors Begin
Your revenue cycle begins before the patient arrives and continues until the account is accurately resolved. Each stage has a specific purpose, but even a small error can affect every step that follows. Maison Dexara provides audits, training, and education to help prevent errors and protect your revenue cycle.
Scheduling & Pre-Registration
The appointment is scheduled and the patient’s basic demographic, insurance, contact, and service information is collected before the visit.
Incorrect names or birth dates, incomplete insurance information, the wrong appointment type, duplicate accounts, or missing contact details.
Eligibility & Benefits Verification
Active coverage, benefits, copays, deductibles, limitations, exclusions, and network status are confirmed before services are provided.
Inactive coverage, the wrong payer selected, benefits misunderstood, network status not verified, or inaccurate patient responsibility estimates.
Prior Authorization & Referrals
Required payer authorizations, physician referrals, and service approvals are obtained, validated, and documented.
Authorization not requested, the wrong procedure approved, expired authorization, missing referrals, incorrect service dates, or incomplete supporting records.
Patient Registration & Check-In
Demographic and insurance information is confirmed, required forms are completed, and applicable upfront payments are collected.
Outdated insurance cards, incorrect addresses, transposed policy numbers, missing signatures, incorrect guarantor information, or copays not collected.
Clinical Documentation & Charge Capture
The provider documents the encounter and all billable services, procedures, supplies, medications, and related charges are captured.
Missing or incomplete notes, services not recorded, delayed charge entry, unsupported services, inconsistent records, or charges omitted from the encounter.
Medical Coding & Claim Creation
CPT, HCPCS, ICD-10, modifiers, units, provider details, and other claim information are assigned based on the clinical documentation.
Incorrect codes, missing modifiers, mismatched diagnoses, invalid units, unbundling, upcoding, omitted charges, or coding unsupported by the record.
Claim Scrubbing & Submission
Claims are reviewed for errors, checked against payer requirements, and submitted to the correct insurance company or claims administrator.
Incorrect payer IDs, missing claim fields, formatting errors, duplicate submissions, invalid provider information, or missed timely-filing deadlines.
Payer Adjudication & Payment Posting
The payer processes the claim, determines financial responsibility, issues an ERA or EOB, and payments and adjustments are posted.
Incorrect posting, inaccurate contractual adjustments, missed underpayments, payments applied to the wrong account, or secondary claims not generated.
Denial Management & A/R Follow-Up
Rejections, denials, unpaid claims, aging balances, and underpayments are researched, corrected, appealed, and followed through resolution.
Denials not worked promptly, incorrect corrections, missed appeal deadlines, inadequate documentation, repeated resubmissions, or balances left unresolved.
Patient Billing & Account Resolution
Accurate statements are issued, payments are collected, payment options are discussed, and the account is reconciled and appropriately resolved.
Incorrect patient balances, confusing statements, insurance balances transferred too early, missed payments, poor communication, or improper collections activity.