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A Guide to Avoiding RCM Worst-Case Scenarios: Part 1

RCM Worse Case Scenario Part 1

What does a complete healthcare experience look like?

In some cases, the treatment portion of patient care is viewed as the standard by which patient experiences are graded. However, treatment is only one half of that journey. The other half, the patient’s financial experience, begins before they ever walk through a hospital’s door.

As soon as a patient picks up the phone to schedule an appointment or logs into a hospital website, their financial experience has begun.

This two-part revenue cycle management series covers some of the common pitfalls hospitals can stumble into when it comes to the patient’s financial journey.

Beginning with the front-end of revenue cycle management, the first part of this series addresses worst-case scenarios that can occur between patient registration and clinical documentation. Part two will follow-up with core issues that can arise from claim management to statement processing to managing self-pay healthcare consumers.

But before we get into any of that, let’s meet our fictional patient Frank.

Say Hello to Frank

Frank is a commercial builder. While at a remote worksite Frank shattered several bones in his foot when a pallet of bricks fell off a loader.

After visiting a walk-in emergency clinic, the attending physician refers Frank to a local orthopedic surgeon for an experimental reconstructive foot surgery. We find Frank at the beginning of his financial journey, at the front-end of the revenue cycle management process.

Front-End RCM

The financial portion of Frank’s patient experience begins well-before discharge and includes:

  1. Scheduling and Patient Registration
  2. Upfront Patient Collections
  3. Clinical Documentation and Coding

Errors that occur on the front-end of RCM can easily pop up later when trying to collect from both insurers and patients. From the very first interaction, front desk staff should think of how they can best set the hospital and patient up for billing success.

Step 1: Scheduling and Patient Registration – Worst-Case Scenario: Hospital Footing the Bill

Upon arriving at the community hospital, the registration desk ignores flags that Frank’s insurance may not cover the experimental procedure as well as important worker’s compensation notes. Without proper authorization from the insurance company, it is likely the hospital will not be reimbursed for this procedure.


Front office staff should recognize that Frank is not a patient access or registration professional. He will need help with the insurance and patient billing workflow process during a preregistration call, either initiated by Frank or by the facility. Once Frank has been registered and all coverage verified, the registrar will need to let him know what is owed at the time of service.

Step 2: Upfront Patient Collections - Worst-Case Scenario: Dazed and Confused Patients

If the most recent price transparency rules are confusing for medical business offices, imagine how confusing it can be for Frank. Unfortunately for Frank, he is only shown the full cost of the procedure instead of the cost minus what his insurance will cover.


Accurate price transparency can help circumnavigate many pre-payment issues. This is also another opportunity to let the patient know that prepayment is an important part of the care process, not just a transaction.

Step 3: Clinical Documentation and Coding – Worst-Case Scenario: Trouble Cracking the Code

The surgery center where Frank is being treated has not installed this quarter’s regulatory billing code updates to their RCM solution or chargemaster. The codes are bundled incorrectly, rules and safeguards for Frank’s treatment are not applied properly, procedures are coded incorrectly, and the charges don’t match.


Ensure that the RCM solution housing the medical coding table files is set up correctly and updated on a regular basis.

Setting Your Patients Up for Financial Success

Where preventative treatments work to improve the care experience, an anticipatory approach to revenue cycle management can help secure a positive billing experience.

By preventing worst-case scenarios on the front-end of the revenue cycle, hospitals are often less likely to encounter issues on the back-end. A minor registration mistake or missed code can move a hospital away from patient-centered care and potentially harm patient loyalty.

MEDHOST works with hospitals to prevent RCM worst-case scenarios, enabling them to promote a positive billing experience. By implementing revenue cycle management best practices, we can help add accuracy and efficiency to provider patient billing workflows, speed payments, and most importantly, increase patient satisfaction.

Stay tuned for part two of our revenue cycle management worst-case scenarios guidebook to see how Frank’s journey concludes on the back-end.

Get the full Avoiding Common RCM Pitfalls: Worst-Case Scenario Handbook. Download part one in full at

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