Your Revenue Cycle Management Data Template

The Activity Name describes a distinct action or milestone in the revenue cycle lifecycle. Examples include 'Service Rendered', 'Claim Submitted', 'Remittance Received', 'Payment Posted', and 'Account Written Off'. Each activity represents a step in the process that consumes time and resources.

This attribute is fundamental to process mining as it defines the nodes in the process map. Analyzing the sequence, frequency, and duration of these activities allows for the visualization of the actual process flow, comparison against a designed model, and identification of deviations, rework loops like claim denials, and inefficiencies.

This attribute defines the steps of the process, which is essential for discovering and visualizing the process map, identifying rework, and analyzing process conformance.

Often found in event logs, transaction tables, or derived from status change records in the billing or claims module.

The Billing Event ID is a unique key assigned to each instance of a billable service, from initial charge capture to final payment or write-off. It acts as the central thread connecting all related activities, such as claim creation, submission, denial, and payment posting, for a specific service encounter.

In process mining, this attribute is crucial for reconstructing the end-to-end journey of each billing event. By grouping all related activities under a single Billing Event ID, analysts can visualize process flows, identify bottlenecks, measure cycle times, and understand the variations in how different cases are handled. It forms the foundation for all case-centric analysis within the revenue cycle.

It is the essential case identifier that links all related activities together, enabling the reconstruction and analysis of the entire revenue cycle for each billable service.

This is typically a primary key in billing transaction or financial event tables.

The Event Timestamp marks the point in time that an activity occurred or was logged. It provides the chronological context for all events within a case, forming a timeline from the beginning to the end of the revenue cycle.

Timestamps are the backbone of performance analysis in process mining. They are used to calculate critical KPIs such as total cycle time, the duration between specific activities, and waiting times. By analyzing timestamps, organizations can identify bottlenecks where cases spend the most time, measure adherence to service level agreements, and understand the temporal dynamics of the process.

It provides the chronological data required to calculate cycle times, identify bottlenecks, and analyze the performance and efficiency of the process.

This information is typically available in transaction logs, audit trails, or as a 'creation date' or 'status change date' field in event tables.

This attribute records when the data was last pulled from the source system. It is a metadata field that is critical for understanding the freshness and timeliness of the data being analyzed. It reflects the latency of the data pipeline and indicates how current the process mining analysis is.

In process mining dashboards and analyses, the Last Data Update timestamp provides context to the user about the data's currency. It is essential for operational monitoring to know if the view represents the process state from five minutes ago or from last night. This helps in managing user expectations and ensuring that decisions are made based on data of a known age.

It provides crucial context about the timeliness and freshness of the data, ensuring that analysis and decisions are based on an understood timeframe.

This is typically added during the data extraction, transformation, and loading (ETL) process and is stored as a metadata column in the event log.

The Source System attribute identifies the origin of the data for a specific event. In a complex IT landscape, the revenue cycle process often spans multiple systems, such as an Electronic Health Record (EHR) system for service rendering, a dedicated billing system for claim submission, and a separate collections platform.

Knowing the source system is valuable for data validation, troubleshooting, and understanding process fragmentation. It can help identify inconsistencies between systems or reveal process steps that are managed in different applications, which can be a source of data transfer delays or errors. This analysis helps in assessing the integration and efficiency of the overall IT architecture supporting the process.

It helps in understanding process fragmentation across different IT systems and is crucial for data validation and identifying system-specific bottlenecks.

This information is often available as a standard field in data extracts or can be derived based on the source table or file from which the data was obtained.

The Adjustment Amount represents the portion of the billed amount that is not expected to be collected from the payer or patient for reasons such as contractual agreements, discounts, or write-offs. These adjustments reduce the total accounts receivable and are a normal part of the revenue cycle.

Analyzing adjustment amounts and their associated reasons is key to understanding revenue integrity. High or unexpected adjustment levels can signal issues with charge capture, coding, or contract management. Process mining can help identify which process variants or specific activities lead to higher adjustment rates, allowing for targeted root cause analysis to maximize revenue realization.

It helps in analyzing revenue leakage by tracking write-offs and contractual allowances, highlighting potential issues in contracting or billing processes.

This value is typically recorded in financial adjustment tables or payment posting modules.

The Billed Amount represents the total charge for services rendered as submitted on a claim or invoice. It is the starting financial value of the billing event and serves as the baseline from which all subsequent financial transactions, such as payments and adjustments, are measured.

In process mining, analyzing the Billed Amount is fundamental to understanding the financial impact of process inefficiencies. It can be used to segment cases into high-value and low-value categories, revealing if certain process problems disproportionately affect high-revenue claims. Correlating this amount with metrics like cycle time or denial rate helps prioritize improvement efforts on issues that have the greatest financial consequences.

It establishes the initial financial value of a case, allowing for financial impact analysis of process inefficiencies like delays and denials.

This is a core financial attribute found in charge capture, billing, or claims transaction tables.

When a payer rejects a submitted claim, they provide a Denial Reason Code to explain why the claim was not paid. These codes often follow industry standards, like Claim Adjustment Reason Codes (CARCs), and point to specific issues such as 'Service Not Covered', 'Duplicate Claim', or 'Additional Information Required'.

This attribute is one of the most powerful for root cause analysis in the revenue cycle. By analyzing the frequency and financial impact of different denial reasons, organizations can pinpoint the upstream process failures that lead to denials. For example, a high number of denials for 'Incorrect Patient Information' points to problems in the patient registration process. This allows for data-driven improvements to prevent future denials and improve the first pass payment rate.

It is crucial for root cause analysis of claim denials, enabling targeted improvements to front-end and mid-cycle processes to prevent future revenue loss.

This information is sourced from the electronic remittance advice (ERA) or explanation of benefits (EOB) files received from payers.

The Payer Name identifies the primary entity to which a claim is submitted for reimbursement. Payers can include commercial insurers like Aetna or UnitedHealthcare, government programs like Medicare or Medicaid, or other entities. Each payer has its own unique set of rules, submission requirements, and payment behaviors.

This attribute is critical for analyzing revenue cycle performance. By segmenting the process by payer, organizations can identify which payers have the highest denial rates, longest payment cycles, or most frequent requests for additional information. This analysis enables targeted interventions, such as renegotiating contracts, tailoring submission processes for specific payers, and focusing denial management efforts where they are most needed.

It allows for segmentation of performance metrics, such as denial rates and payment times, by payer, which is crucial for targeted improvements and contract negotiations.

This information is typically found in the patient registration, insurance, or claims data associated with the billing event.

This attribute identifies the organizational unit associated with a particular process step, such as 'Patient Access', 'Coding', 'Billing', or 'Collections'. It helps in understanding how work is distributed and handed off between different teams.

Analyzing the process from a departmental view is essential for understanding cross-functional collaboration and identifying bottlenecks that occur at the handoff points between teams. It allows managers to see which departments are involved in specific process variants, measure departmental efficiency, and allocate resources more effectively. This analysis can highlight systemic issues within a department that may be impacting the entire revenue cycle.

It helps identify inter-departmental bottlenecks and analyze performance by functional area, revealing opportunities for better cross-team collaboration.

This information can be part of the transaction data or derived from the master data associated with the responsible user.

The Responsible User attribute links a process step to the individual or system that executed it. This could be a coder completing medical coding, a billing specialist submitting a claim, or an automated bot posting a payment. Tracking the user provides a human or system-centric layer to the process analysis.

Analyzing process performance by user or team can reveal training opportunities, identify high-performing individuals, and ensure proper workload distribution. It is also critical for compliance and audit purposes, allowing for clear accountability for each action taken. This attribute enables a detailed analysis of resource performance and utilization.

It enables analysis of team and individual performance, workload distribution, and automation rates, providing insights into resource efficiency and identifying training needs.

Typically found in transaction logs or audit trails as 'User ID', 'Employee ID', or 'Processor' fields.

The Service Category classifies the type of care or service provided to the patient. This could be a high-level classification like 'Inpatient' versus 'Outpatient', or a more specific departmental category like 'Surgery', 'Emergency', or 'Laboratory'. Different service categories often have distinct billing rules, payer requirements, and process flows.

Segmenting the revenue cycle process by Service Category is essential for a meaningful analysis. It allows organizations to compare the performance of different service lines, for example, to see if the denial rate for surgical procedures is higher than for consultations. This level of detail helps isolate problems and tailor improvement initiatives to the specific operational context of each service area.

It allows for performance comparison across different service lines, revealing variations in efficiency, denial rates, and payment cycles that are specific to certain types of care.

This information is usually available in the charge detail records or can be derived from the patient class, department, or procedure codes.

The Account Status provides a snapshot of where a billing event stands in its lifecycle at any given time. This status reflects the outcome of the most recent activity, indicating whether the account is open and awaiting payment, closed, sent to collections, or in another state.

While process mining reconstructs the flow of activities, the Account Status attribute is valuable for filtering and segmenting cases based on their current condition. It is particularly useful for operational monitoring dashboards that need to show the volume and value of accounts in different stages, such as the total accounts receivable currently pending payer response or the number of accounts recently sent to a collections agency.

It provides a current-state snapshot of cases, which is useful for operational dashboards and for segmenting analysis based on where accounts are in their lifecycle.

This is typically a status field on the main patient account or billing event record in the patient accounting system.

Similar to a denial reason, the Adjustment Reason explains why a portion of the billed amount was written off or adjusted. These reasons clarify whether an adjustment was due to a contractual obligation with a payer, a charity care policy, a small balance write-off, or a correction for a billing error.

Analyzing Adjustment Reasons provides insights into revenue integrity and financial performance. It helps differentiate between expected, contractual adjustments and preventable write-offs due to internal errors. By filtering the process map based on specific adjustment reasons, analysts can identify process weaknesses that lead to avoidable revenue loss and focus improvement efforts accordingly.

It provides context for financial adjustments, helping to differentiate between contractual obligations and preventable revenue loss due to process errors.

Found in financial transaction tables within the billing or patient accounting system, often linked to adjustment or write-off transactions.

The Claim ID is a specific identifier for the bill sent to an insurance company. A single billing event might result in multiple claims if it needs to be billed to primary, secondary, and tertiary payers, or if a claim is corrected and resubmitted.

Tracking the Claim ID is important for understanding the details of the payer interaction process. It allows for the analysis of rework loops involving claim resubmissions and helps trace the status of a specific bill sent to a payer. Analyzing the process by Claim ID can provide a more granular view of the claim submission and resolution lifecycle than looking at the Billing Event alone.

It enables detailed tracking of claim submissions and resubmissions, providing a granular analysis of interactions with payers and rework loops.

This identifier is generated by the billing system upon claim creation and is stored in claims management tables.

The Outstanding Balance represents the amount of money still due to be collected for a billing event. It is typically calculated as the Billed Amount minus any Paid Amounts and Adjustment Amounts. This value changes over the lifecycle of the case as payments and adjustments are posted.

This attribute is a key indicator of accounts receivable health. In process mining, analyzing the outstanding balance at various stages of the process helps in managing A/R aging and prioritizing collections efforts. It can be used to identify which types of cases or process paths tend to have high residual balances, signaling problems in payment or denial resolution.

It is a key measure of accounts receivable and collection effectiveness, helping to prioritize follow-up activities and analyze A/R aging.

Often calculated from billed, paid, and adjusted amounts. It may also be stored as a field in an accounts receivable or patient accounting system.

The Paid Amount is the cumulative sum of all payments posted against a specific billing event. This includes payments from primary and secondary insurance payers as well as payments made by the patient. It represents the actual cash collected for the services rendered.

Analyzing the Paid Amount is essential for measuring the financial success and efficiency of the revenue cycle. Comparing the Paid Amount to the Billed Amount provides insights into net revenue and collection rates. In process mining, this attribute helps quantify the financial outcome of different process paths and can be used to identify characteristics of claims that are paid in full and on time versus those that are not.

It measures the actual cash collected for a case, which is critical for evaluating collection effectiveness and the overall financial performance of the process.

This information is located in payment posting or cash application transaction tables.

The Patient ID is a unique key assigned to an individual patient within the healthcare system's master patient index. This identifier links all of a patient's clinical and financial encounters over time.

While the Billing Event ID is the case for a single service, the Patient ID allows for a broader analysis across multiple encounters for the same patient. This can reveal recurring issues, such as repeated registration errors or patterns of service utilization. It can also be used to analyze the complete financial journey of a patient, which is valuable for understanding patient liability and loyalty.

It allows for analysis across multiple billing events for the same patient, helping to identify recurring issues and understand the patient's overall financial journey.

This is a primary identifier found in virtually all clinical and financial systems, originating from the patient registration or EHR system.