Hospital revenue cycle and billing guides

The revenue cycle is everything that happens between authorizing care and money in the hospital's bank account. In these guides you'll see each step, who owns it and where revenue is lost, from front-desk registration to reconciling the payer's payment.

1. Hospital revenue cycle
2. Revenue Cycle Management (RCM): what it is and how it works in Brazilian hospitals
3. Revenue cycle vs. hospital billing: what's the difference
4. Hospital revenue leakage: a map of where hospitals lose money
5. Revenue cycle stages: who does what in the front end, middle and back end
6. Hospital claim closing: how to reduce discharge-to-bill time
7. Hospital billing department: structure, roles and staffing
8. Revenue cycle in mid-size hospitals: priorities and common mistakes
9. Integrating medical records and billing: how clinical care protects revenue
10. Revenue and denials committee: how to set it up and run it
11. Revenue cycle in clinics and diagnostic centers vs. hospitals

A claim denial is the part of the claim the payer doesn't pay. These guides explain the types of denials, the most frequent reasons, how to appeal on time and how to measure denials correctly, separating what's contested from what's actually lost.

1. Hospital claim denials
2. Types of denials: administrative, technical and across-the-board
3. Denial appeals: how to file one, step by step, with a ready-to-use template
4. Denial reasons: the most common ones and how to avoid each one
5. TISS denial codes: what each message in table 38 means
6. Denial rate: formula, industry benchmark and target
7. Initial, final and accepted denials: what each one measures
8. Denial appeal deadlines: what RN 503/2022 says
9. OPME denials: causes and how to prove use
10. Supplies and drug denials: the most common causes and how to prevent them
11. Hospital daily rate and fee denials: causes, codes and prevention
12. Physician fee denials: team, surgical approach and add-ons
13. Across-the-board denials: what they are and how to contest them
14. Denial management: process, owners and KPIs
15. Oncology and chemotherapy denials
16. ICU and long-stay denials
17. Emergency department and urgent care denials
18. Home care denials

Billing well means turning care into a claim the payer accepts on first review. These guides cover the TISS standard, the TUSS table, claim forms and the rules for each item on the claim.

1. Hospital billing
2. The TISS standard: what it is, its components and how it works
3. The TUSS table: what it is, how to look up and use the codes
4. TISS claim forms: SP/SADT, inpatient, physician fees and other expenses
5. CBHPM table: what it is, how the tiers work and when it's used
6. Brasíndice and Simpro: how to price supplies and drugs on the claim
7. How to bill OPME: authorization, invoice and traceability
8. Hospital daily rates and fees: what can and can't be charged
9. Physician fees on the hospital claim: participation level and add-ons
10. Hospital bundles: how to price and bill without losing margin
11. TISS XML batches: the most common submission errors and rejections
12. Claim review and remittance statements: how to read and reconcile them
13. Hospital interim billing: when and how to bill long inpatient stays
14. Claim submission deadlines by payer: how to track them and never miss one
15. Billing cath lab and high-cost procedures
16. Emergency department vs. elective admission billing: practical differences

Many denials start before care, at eligibility verification and prior authorization. These guides show what to check at the front desk, what ANS requires of payers and what to do when facing a denial.

1. Prior authorization
2. Eligibility verification: the front desk checklist
3. Authorization denials: what the payer must disclose and how to reverse them
4. ANS Procedures List (Rol): what it covers and what changed with the Supreme Court
5. ANS maximum care timeframes: full table and what to do when they're exceeded
6. Expired authorization numbers: why they happen and how not to lose the procedure
7. Utilization Guidelines (DUT): how to document to secure coverage
8. Medical boards and technical disagreements: how the ANS rule works
9. Inpatient stay extensions: how to request them and avoid daily-rate denials
10. OPME authorization: quotes, suppliers and deadlines
11. Urgent and emergency coverage: what the payer is required to cover
12. Waiting periods and temporary partial coverage: impact on the hospital claim
13. Authorization center: how to structure team, workflow and KPIs

Auditing the claim before the payer does is the cheapest way to avoid denials. These guides explain the types of audit, how to review every claim before submission and what must be documented in the medical record.

1. Medical claims auditing
2. Types of audit: prospective, concurrent and retrospective, and when to use each
3. Hospital claim pre-audit: how to review 100% without slowing billing
4. Medical record audit: what must be documented so the claim isn't denied
5. Physician audit: CFM rules and the limits of the payer's auditor
6. Nursing audit: the nurse auditor's role and Cofen rules
7. How to negotiate with the payer's auditor: technique and documentation
8. Clinical documentation for billing (CDI): what physicians need to record
9. On-site vs. electronic claims audit: advantages and risks
10. Hospital billing specialist: what they do, training, skills and auditor career

Without KPIs, revenue loss only shows up when cash runs short. These guides bring the formulas for the main revenue cycle KPIs, industry figures for comparison and calculators to measure your hospital.

1. Revenue cycle KPIs
2. Days in A/R for hospitals: how to calculate and reduce the average collection period
3. What payer delays cost: the price of each extra day to get paid
4. Tax reform for hospitals: what changes with IBS and CBS
5. Anahp Observatory: what the numbers say in each edition
6. Hospital accounts receivable aging: how to build and analyze it by payer
7. Payer payment reconciliation: step by step
8. Hospital accounts receivable: allowances, write-offs and losses
9. Hospital working capital: how to fund operations with long collection periods
10. Payer receivables financing: when it pays off
11. Discharged not final billed (DNFB): the forgotten KPI and how to reduce it
12. Hospital margin and EBITDA: how much the revenue cycle weighs on results
13. Hospital revenue forecasting: how to project cash by payer

Hospitals depend on the rules of the health plan market. These guides explain how Brazilian private healthcare works, what ANS regulates, what the payer contract must cover and how to negotiate rate adjustments and deadlines.

1. Brazilian private healthcare
2. The ANS rules that affect hospitals
3. RN 503/2022: what the payer contract must say
4. Hospital payment models: fee for service, bundles, DRG and value
5. Negotiating rate adjustments with payers: data, calendar and arguments
6. Late payer payments: hospital rights and how to collect
7. Hospital–payer contract: essential clauses and pitfalls
8. DRG in Brazil: how it works and how hospitals prepare
9. Payer vertical integration: the impact on independent hospitals
10. Brazil's largest health insurers: ranking and payment profile
11. Loss ratio: what it is and why it changes the relationship with hospitals
12. Payer financial results: what ANS data tells hospitals
13. Unimed interchange: how to bill care for members of other cooperatives
14. Provider network termination and replacement: what ANS rules say
15. Rio de Janeiro hospital market: payers, networks and outlook
16. NIP and ANS complaints: what hospitals need to know

Not every hospital needs more billing specialists; many need a different model. These guides compare in-house and outsourced billing, show how to choose a partner and where artificial intelligence already helps the revenue cycle.

1. Hospital billing outsourcing
2. In-house vs. outsourced billing: cost, risk and results compared
3. How to choose a hospital billing company: 12 criteria
4. AI in hospital billing: what already works and the limits
5. AI for denial prevention: how it works in practice
6. Billing automation (RPA): what to automate first
7. ROI of a revenue cycle project: how to build the business case
8. Hospital management systems and the revenue cycle: what to look for
9. Healthcare interoperability: TISS, HL7 FHIR and data exchange with payers
10. LGPD in billing and data exchange with payers
11. Billing transition: how to change the model without stopping operations