Stage 1 — Patient Scheduling and Registration

The revenue cycle begins at scheduling — not at billing. Every piece of information collected at the front desk either supports or undermines the claim that will eventually be submitted for that encounter.

What must be captured accurately at registration:

• Patient's legal name — exactly as it appears on the insurance card and in the payer's system
• Date of birth — used by payers for member identification and eligibility verification
• Insurance ID number and group number — copied directly from the insurance card, not entered from memory
• Payer name and plan type — critical for Austin practices that must distinguish between traditional Medicare, Medicare Advantage (UnitedHealthcare, Humana Gold Plus, Aetna, BCBS TX Blue Advantage), and ACA Marketplace plans (Ambetter, BCBS TX) at the point of registration
• Secondary insurance information — including Medicare as primary for dual-eligible patients and STAR+PLUS Medicaid patients
• Referring provider information — required for certain managed care referrals and commercial plan claims
• Self-insured employer plan identification — Austin's large tech-sector workforce means a significant share of patients carry self-insured employer plans (Sana Benefits, UnitedHealthcare, Cigna) with unique billing rules that differ from the same insurer's standard commercial plans

Registration errors are the upstream source of many downstream denials. A transposed insurance ID number at scheduling becomes an eligibility denial at the payer level. A missing secondary payer record becomes a coordination-of-benefits error at payment posting.

Stage 2 — Insurance Eligibility Verification

Eligibility verification is the most consistently underperformed step in the revenue cycle for Austin practices. Many practices verify eligibility at scheduling — once — and assume it remains accurate through the appointment date. It does not.

What eligibility verification must confirm:

• Active coverage on the date of service — not just on the date of scheduling
• Deductible status — how much of the patient's annual deductible has been met
• Copay and coinsurance amounts — for accurate patient collection at the point of service
• Covered benefits — whether the specific service being scheduled is a covered benefit under the patient's plan
• Network status — whether the provider is in-network under the patient's specific plan, not just the payer generally
• Authorization requirements — whether the scheduled service requires prior authorization before it can be rendered
• Medicare Advantage plan type — which specific MA plan the patient holds and which carrier administers it, since each carries different prior auth and referral rules
• TMHP managed care plan — which specific managed care organization holds the patient's current Medicaid enrollment (STAR, STAR+PLUS, or STAR Kids)
• ACA Marketplace enrollment status — Austin's growing ACA population is subject to mid-year plan changes and subsidy-related enrollment terminations

When eligibility must be verified:

Eligibility must be verified at scheduling and again within 24 to 48 hours before the appointment date. For Medicaid patients, re-verification is critical because TMHP managed care enrollment changes monthly. A patient who was enrolled with one managed care plan at scheduling may have switched plans by the appointment date.

Stage 3 — Prior Authorization Management

Prior authorization is the step where the most expensive, most avoidable denials originate. A service rendered without a valid prior authorization on file cannot be billed retroactively in most cases — the revenue is simply lost.

Services that commonly require prior authorization in Austin:

• Advanced imaging — MRI, CT, and PET scans require prior authorization under most Austin commercial payers, including UnitedHealthcare's mandatory electronic PA system, BCBS Texas, Aetna, and Cigna
• Surgical procedures — elective and semi-elective surgical procedures require PA under TMHP managed care and all major Austin commercial plans
• Specialty referrals — under certain Medicare Advantage plans operating in Travis County, specialist visits require a referral and, for many procedures, an additional prior authorization
• Behavioral health services — session limits, telehealth authorizations, and intensive outpatient program approvals require advance authorization under virtually every Austin payer; behavioral health is a high-growth specialty in Austin, where PA failures are the single largest source of revenue loss
• Home health and DME — durable medical equipment and home health services require prior authorization under TMHP and Medicare Advantage plans

The prior authorization workflow:

1. Identify whether the scheduled service requires authorization for the patient's specific plan
2. Submit the PA request with supporting clinical documentation before the appointment date
3. Track the authorization status and confirm approval before the patient arrives
4. Document the authorization number and attach it to the claim at submission
5. Verify that the authorization covers the specific procedure codes that will be billed — not just a general service category

Stage 4 — Medical Coding

Medical coding translates clinical documentation into the standardized codes that payers use to process claims. Coding accuracy determines both the revenue generated by each claim and the compliance risk associated with it.

Code sets used in Austin RCM:

• CPT codes — all professional services, office visits, procedures, and tests
• ICD-10-CM — diagnosis coding for outpatient and professional services to the highest level of specificity supported by documentation
• ICD-10-PCS — inpatient procedure coding for hospital-based providers
• HCPCS Level II — supplies, durable medical equipment, drugs, and non-CPT services
• E/M codes — evaluation and management coding under the 2021 AMA framework, using medical decision-making or total provider time

Common coding errors that generate denials in Austin:

• ICD-10-CM codes assigned without full specificity — using a non-specific code when a more specific code is supported by documentation
• Missing or incorrect modifiers on multi-procedure encounters — particularly BCBS Texas bundling edits that require modifier 59 or X-modifiers to establish separate and distinct procedures
• NCCI edit violations — procedure code pairs that trigger automatic bundling without correct modifier application
• E/M level mismatch — billing a higher E/M level than the documented medical decision-making supports
• Telehealth billing errors — Austin's large and growing telehealth provider base regularly encounters coding and place-of-service errors under Texas-specific telehealth reimbursement rules

Stage 5 — Claim Scrubbing and Submission

Before any claim is submitted to a payer, it passes through a claim scrubbing process — an automated and manual review that catches errors before they generate denials.

What claim scrubbing reviews:

• NCCI edit compliance — procedure code pairs that trigger automatic bundling
• LCD/NCD policy alignment — Local Coverage Determinations and National Coverage Determinations for Medicare-billed services
• Modifier validation — confirming that all modifiers are appropriate, necessary, and payer-accepted
• Diagnosis code linkage — confirming that every procedure code is linked to a supporting diagnosis code
• Payer-specific formatting — confirming that claim format meets the specific requirements of each payer, including TMHP, Medicare, Medicare Advantage, and all major Austin commercial plans

Clean claims are submitted electronically within 24 to 72 hours of the patient encounter. Delayed submission increases A/R days and — for payers with short timely filing windows — increases the risk of timely filing denials.

Stage 6 — Denial Management and Appeals

Denied claims require immediate, systematic response. Every denial that is not worked within the payer's appeal window becomes unrecoverable revenue.

The denial management workflow:

1. Receive the denial and log it with the denial reason code, payer, and original submission date
2. Perform root-cause analysis — determine whether the denial is a coding error, authorization miss, eligibility issue, or timely filing problem
3. Correct the error and prepare the appeal with supporting documentation specific to the denial reason
4. Submit the appeal within the payer's timely filing window — typically 30 to 180 days from the denial date depending on the payer
5. Track the appeal status and escalate to payer provider relations if no response is received within the payer's stated turnaround time
6. Document the outcome and analyze whether the denial pattern indicates a systemic process failure that requires a front-end correction

Stage 7 — Payment Posting and Patient Billing

Payment posting is the step where insurance payments are matched to the corresponding claims, contractual adjustments are applied, and patient responsibility balances are identified.

What accurate payment posting requires:

• ERA (Electronic Remittance Advice) and EOB (Explanation of Benefits) matched to correct claims
• Contractual adjustments posted at the correct contracted rate — not estimated
• Underpayments are flagged for audit when the payment received is less than the contracted rate
• Patient balance is identified and billed promptly after insurance payment is posted
• Secondary payer billed immediately after primary payer payment is posted — critical for dual-eligible patients under Medicare Advantage and TMHP STAR+PLUS

Stage 8 — Reporting and Continuous Improvement

Monthly financial reporting closes the revenue cycle loop — turning billing data into operational intelligence.

What monthly RCM reports should cover:

• Net collections by payer and by provider
• Denial rate by payer and by denial reason code
• First-pass claim acceptance rate
• A/R aging distribution — 0–30, 31–60, 61–90, 91–120, and 120-plus day buckets
• Write-off analysis by category
• Coder productivity and coding accuracy metrics
• Prior authorization approval and denial rates by payer

For Austin practices, payer-specific reporting is essential — overall metrics can mask poor performance on Medicare Advantage or TMHP claims that is offset by strong commercial payer results.

Frequently Asked Questions

Why does eligibility verification need to happen twice — at scheduling and before the appointment?

Insurance coverage changes between scheduling and the appointment date — particularly for Medicaid patients whose TMHP managed care enrollment changes monthly, and ACA Marketplace enrollees who may lose or change coverage mid-year. A single eligibility check at scheduling does not guarantee accurate payer information on the date of service.

What happens if a prior authorization is not obtained before the service?

Most payers — including TMHP managed care plans and major Austin commercial insurers — do not allow retroactive authorization. Services rendered without a valid prior authorization on file are denied, and the denial is typically not reversible through the standard appeal process. The revenue is lost.

How quickly should denied claims be appealed?

Every denied claim should receive a documented response within 24 to 48 hours of receipt. Payer appeal windows range from 30 to 180 days, depending on the payer — but the earlier an appeal is submitted with complete documentation, the higher the probability of successful recovery.

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