Revenue cycle management for clinics and practices
Claims worked from the eligibility check to the posted payment, run remotely, with a monthly report that shows where every open claim stands.
- Delivery
- Remote, with a first visit where it helps
- Saudi claims
- Through nphies, coded in the Saudi Billing System
- Every month
- The revenue cycle report and the open-claims list
- Scope
- The full cycle, or coding, denials or follow-up on their own
- Onboarding
- Timeline set at scoping
Revenue cycle management is the work between a patient visit and the money arriving: checking coverage, coding the visit, submitting a clean claim, working denials, chasing unpaid claims and posting payments. We run it remotely and report every month on what is paid, pending and denied. In the Kingdom, the transactions pass through nphies.
- 01 Enquiry
- 02 Survey
- 03 Scope
- 04 Plan
- 05 Execute
- 06 Evidence
- 07 Review
- 08 Next cycle
Revenue cycle management for clinics and practices sits at step 6 of the same eight steps, with health's names. You receive the evidence index, or the monthly revenue cycle report.
Where the money actually leaks
Practices rarely lose money to one dramatic denial. They lose it to claims nobody looked at again.
A claim is refused at the exchange for a missing policy number, and because it never reached the payer, nobody counts it as a denial. A denial arrives, is posted as a zero payment, and is never answered. The payer pays less than the contract rate, and the difference is written off as an adjustment. A patient's share is never collected. Then the payer's resubmission window closes, and the claim is gone.
A denial can start at registration, at authorisation, in the claim data or in the coding. Registration errors begin at the front desk, which is why a billing service that never talks to the front desk keeps fixing the same claims.
The cycle, one handover at a time
Each step, what happens at it, and the transaction it becomes on nphies for a claim in the Kingdom.
| Step | What happens | On nphies |
|---|---|---|
| Eligibility | Coverage and benefits confirmed before the visit, at every visit. | Eligibility request and response |
| Authorisation | Approval obtained for services that need it, for the service that will actually be delivered. | Prior authorisation |
| Coding | The visit coded from the provider's documentation. An unclear note goes back to the provider as a query, and nothing is coded that the note does not support. | Saudi Billing System procedures, ICD-10-AM diagnoses |
| Claim | Checked against the payer's rules, then submitted. | Claim, or batch claim |
| Validation | Refusals at the exchange caught and fixed quickly, because they never reach the payer and nobody else will see them. | Validation response |
| Payment posting | Payments and adjustments posted line by line and checked against the contract. | Payment notice and reconciliation |
| Denials | Worked by reason and root cause, then corrected, resubmitted or appealed. | Insurer rejection reasons |
| Follow-up | Unpaid claims chased by age and payer before the window closes. | Status check and communication |
| Patient share | Statements and payment plans, where they are in scope. | Patient share on the claim |
| Report | The month's results, explained on a call. | Built from every row above |
On paper, every month
The day-one baseline
Outstanding balances by age and payer on the day we start, the number every later report is measured against.
The monthly revenue cycle report
Charges, payments, AR by age, denials by reason and underpayments, each with its definition, and a call to go through it.
The open-claims list
Every unpaid claim, its status, the next action and the date of that action.
The denial log
Each denial by reason, payer and value, with the root cause and the fix made at source.
The front desk checklist
A short list built from your own denial reasons, for the people who register patients.
The coding query log
Queries sent to providers where a note did not support a code, answered and outstanding.
Changing billing provider without losing a month
Switching is where practices lose money, because nobody owns the claims in the gap. The onboarding timeline is set at scoping, and claims keep moving while it runs.
- 01
Agree the old claims
Who works claims with dates of service before the start date: your previous biller, us, or a split by payer. Agreed in writing.
- 02
Close the previous biller's access
The date their access ends, written down, so no claim is worked by two teams at once.
- 03
Take the baseline
A snapshot of AR by age and payer, so every later report compares against something real.
- 04
Set up in your name
Exchange access, payer contracts and fee schedules loaded so underpayments can be seen. Contracts and accounts stay in your name.
- 05
Oldest risk first
Open claims worked in order of window risk, then value, so the claims closest to expiry go first.
- 06
First monthly report
The month's results against the baseline, explained on a call.
A specialist clinic whose biller left
A specialist clinic in Riyadh bills several insurers through nphies. Its in-house biller has left, and the rejections and open claims have not been worked for two months.
The clinic first decides who owns the claims already in flight. The day-one snapshot then shows three problems. A block of claims over ninety days old has no follow-up notes. A run of eligibility rejections was never rechecked. Payment notices were posted without being checked against the contract, so short payments passed as adjustments.
We sort the open claims by how close each is to the insurer's resubmission window first, and by value second. Rejections are logged by reason. The eligibility pattern traces to a front desk that checks coverage when a patient first registers, not at every visit, and the checklist changes. Contract rates are loaded, and the next month's payment notices are checked line by line.
The clinic ends up holding the day-one baseline, a rejection log with root causes, a list of claims at window risk, a front desk checklist and, from then on, the monthly report and the open-claims list.
Three things buyers ask to see
Definitions, not adjectives
A monthly report and a call to go through it. Your own figures arrive every month, and you can check them against your bank account.
- Charges, payments and adjustments, by payer, for the month and the year so far
- AR by age, in 30-day buckets, by payer
- Days in AR: outstanding AR divided by average daily charges
- First-pass acceptance: the share of claims accepted on first submission
- Denials by reason, with the count, the value, the root cause and the fix
- Underpayments: claims paid below the contracted rate, with the amount owed
- Window risk: claims within 30 days of a payer's limit, with the action taken
- Coding queries sent, answered and outstanding
The front desk stays yours
It collects the insurance card and the patient's details, and we give it a short checklist built from your own denial reasons. Providers stay in charge of documentation, and appeals are signed as each payer requires.
- Coverage checked at every visit, not once a year
- Authorisation requested for the service that will be delivered
- Registration details matched to the insurance card
Six things set the quote
Pricing in this industry is usually a fee per claim, a fixed monthly fee or a share of what is collected. We tell you which model we propose for your practice, and why.
- Specialty: coding complexity and denial patterns differ widely between, say, primary care and surgery
- Volume: claims per month, and how evenly they arrive
- Payer mix: each insurer and administrator behaves differently
- Scope: the full cycle, or only coding, denials or follow-up
- The backlog: old AR needs a clean-up before steady-state work
- Patient balances: statements and patient calls add work
Before you hand over a login
Will you promise a collection rate?
No. What you collect depends on your contracts, your documentation and your patients' coverage, and most of that sits with you and your payers. We report your collection figures every month, with definitions, so you can judge the work.
Can you take only part of the cycle?
Yes. Coding, denials or follow-up of old claims can each run on their own. A denial review is a common first scope, because the denial log shows quickly whether the problem sits upstream.
What happens to claims from before you start?
It is agreed in writing before day one: your previous biller, us, or a split by payer. Unowned claims in a switch are the most expensive claims a practice has.
Do you code from our notes?
Yes, and only from them. When a note does not support a code, the provider gets a query, and the query log shows what was asked and what was answered.
Can we leave, and what do we take with us?
Yes, on the notice period in the agreement. You receive the open-claims list with its work notes, the denial log and the last report, so whoever comes next starts from a record rather than a guess.
Around this
Denial management
Denials worked by root cause, as a scope on its own.
Read moreServiceSaudi claims through nphies
Eligibility, prior authorisation, SBS coding and reconciliation on the national exchange.
Read moreSectorClinics and polyclinics
What ITF Health does for outpatient facilities.
Read moreITF DigitalDashboards and reporting
Revenue dashboards built from your own billing data.
Read moreITF CyberPDPL readiness
Health data is sensitive data under the PDPL. The readiness work sits with ITF Cyber.
Read morePart of one system
Every division keeps records to the same standard, so the second one you need works the way the first one did.
Start with a look at your receivables
One month of claims and denials shows where your money is leaking and which step it leaks from.