RCM Operational Challenges

Published On: July 23, 2025Categories: Tags: , ,
An Interview with Megan McMullen, Manager of Client Services

Effective revenue cycle management (RCM) requires more than software. It demands strategy, workflow precision, and proactive problem-solving. We sat down with Megan McMullen, Manager of Client Services to dive into the operational realities behind eligibility, claims, denials, automation, and more. Whether you’re leading a hospitalist group, anesthesia practice, or radiology billing team, these expert insights reveal what separates high-performing RCM operations from those leaking revenue every day.

Q: What’s the most common operational gap you see across new clients before implementing PhyGeneSys?

The lack of integrated, automated workflows to manage the full lifecycle of claims—from eligibility verification through denial management and resubmission. High volume of manual data entry leads to coding inaccuracies, missing patient information, or incorrect modifiers resulting in increased claim denials or underpayments.

Q: How does automation on the front-end, like eligibility and prior authorization, impact downstream performance metrics like denial rate or A/R days?

Accurate and streamlined front-end processes are critical to reducing denial rates and shortening days in accounts receivable. PhyGeneSys’s integrated Real-Time Eligibility (RTE), Real-Time Claim Edits (RTCE), and Charge Error Check configurations enhance front-end accuracy—resulting in cleaner claims, fewer delays, and faster reimbursements.

Q: What are signs that a group’s existing RCM vendor or system setup is costing them revenue or causing workflow inefficiencies?

Elevated denial and rejection rates, increasing days in accounts receivable (AR), and a low first-pass resolution rate are key indicators that the current RCM system is not effectively optimizing workflows—resulting in revenue loss and operational inefficiencies.

Q: What role do integrations — like clearinghouses or EHR systems — play in the overall success of an RCM operation?

Integrated EHR and clearinghouse connections reduce manual data entry by syncing patient demographics, insurance, charges, and clinical documentation in real time. This improves data accuracy, reduces claim rejections, and minimizes billing delays. Direct clearinghouse integrations allow for automated, real-time claims submission, status tracking, and ERA (Electronic Remittance Advice) posting. This shortens the revenue cycle and reduces staff time spent on follow-ups. In short, well-executed integrations are the backbone of a high-performing RCM operation. They eliminate inefficiencies, improve accuracy, accelerate cash flow, and reduce administrative burden—allowing billing teams to shift from reactive cleanup to proactive revenue optimization.

Q: Where do practices typically underestimate the impact of payment posting and reconciliation?

These are both critical control points for revenue integrity, cash flow accuracy, and financial visibility. Without detailed reconciliation, underpayments and denials can go unnoticed causing revenue loss. When done accurately and timely, they help practices maximize reimbursement, reduce errors, improve patient communication, and maintain financial control.

Q: What does a well-built denial management workflow look like, and how does PhyGeneSys help make that repeatable?

Effective denial management starts long before a claim is submitted. The primary objective is to prevent denials from occurring in the first place. PhyGeneSys supports this proactive approach through front-end solutions like EDC/OCR processing, Real-Time Eligibility (RTE), and Real-Time Claim Edits, which help ensure that clean, accurate data is transmitted to the payer. Once claims are adjudicated, ERA auto-posting minimizes manual entry errors and supports efficient payment reconciliation. PhyGeneSys further enhances this with ERA validation and payment action schemes that allow for accurate posting of CARC/RARC codes. These tools ensure that only appropriate denials are routed to follow-up, streamlining review and resolution efforts. To support efficient workflows, PhyGeneSys offers flexible work queue assignments, enabling organizations to route follow-up tasks to specific users based on payer, facility, or provider—ensuring the right staff handle the right claims. Finally, tracking key performance indicators (KPIs) is critical to continuous improvement. Metrics such as denial rate (as a percentage of total claims), first-pass resolution rate, appeal success rate, average days to resolve a denial, and denials categorized by payer, provider, and procedure should all be monitored. PhyGeneSys offers robust reporting and analytics tools that provide the visibility needed to stay ahead of denial trends and optimize your revenue cycle performance.

Q: If a group scores low on the RCM Operations Assessment, what are the first 2–3 things they should do immediately to start improving?

  1. Eligibility/Authorization Checks – prevent denials before they start
  2. Claim & Denial Management – ensure clean claims and quick appeals, and
  3. A/R and Collections – reduce aging and maximize recovery

Want to uncover your own gaps and opportunities?

Download the RCM Operations Assessment Sheet to evaluate your current workflows, identify challenges, and calculate your potential financial upside.

At PHIMED Technologies, we forge true partnerships with healthcare providers and medical billing companies to transform your revenue cycle — combining our innovative PhyGeneSys platform with deep industry expertise to eliminate inefficiencies, automate repetitive tasks, and implement patient engagement strategies that drive substantial revenue growth. Through continuous evolution, streamlined workflows, and transparent data-driven insights, we position your practice for long-term sustainable growth.