Trace billed encounters through payment, denial, and follow-up
A RUSA case study for healthcare and life sciences teams, connecting encounter charges, submitted claims, payer responses, payment allocations, and adjustments for healthcare revenue cycle.
First submission acceptance rate (%)
Payer denial rate (%)
Receivable days
Net collection rate (%)
THE CHALLENGE
Billing totals obscure payer rejections and unresolved receivables
Unrecorded demand
Unfulfilled requests are absent from booking reports.
Roster changes
Available slots change without retained history.
Mixed attendance
Cancellations and no-shows share the same status.
Unfair comparison
Specialties with different consultation needs are ranked together.
THE SOLUTION
Healthcare Revenue Cycle Review Framework
Charge reconciliation
Connect requested, offered, booked, and attended dates.
Slot inventory
Retain effective provider and facility capacity.
Attendance taxonomy
Separate attendance, cancellations, and unnotified absence.
Specialty comparison
Review access using comparable services and booking rules.
THE APPROACH
Encounter Charge Line Matching
Retain fulfilled and unfulfilled appointment requests with requested specialty and first contact date.
Provider Slot History
Version available appointment capacity using effective rosters, protected slots, and authorized schedule changes.
Request Booking Linkage
Connect requested, offered, booked, rescheduled, cancelled, and attended events.
Attendance Status Harmonization
Calculate unpaid balances and ageing using documented net-charge and accounting-period rules.
Denial Follow-Up Assignment
Route recurring denial categories and aged unpaid claims with submission and response evidence.
Revenue Cycle Balance Verification
Test resubmissions and partial receipts without recommending clinical coding or guaranteeing reimbursement.
THE IMPACT
Submission visibility
Missing and rejected claim lines could receive focused review.
Cash clarity
Unallocated payments could be separated from unpaid claims.
Reason context
Recurring payer response categories could guide process investigation.
Receivable accountability
Follow-up cases could carry owners and due dates.
Controlled review
Authorized teams could review recurring denials, unallocated receipts, and aged unpaid claims, with source evidence retained beside the review case.
Measurable evaluation
A pilot could establish baseline values for first submission acceptance rate (%) and assess changes after approved actions. The design would support administrative reconciliation, not recommend clinical coding or guarantee reimbursement.
Explore Healthcare Appointment Access
Work with RUSA Analytics to connect appointment requests, booking events, provider rosters, attendance, and cancellations and create a governed workflow to review unfulfilled requests, idle appointment slots, and repeated late cancellations. Start with a scoped concept or pilot and agreed success measures.
MORE WORK
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