What is revenue cycle management (RCM)?
Revenue cycle management (RCM) is the management, as a single process, of everything between a patient's first contact and the reconciled payment. The key word is management. Every hospital has a revenue cycle; RCM is the decision to run it with an owner, targets and KPIs.
In Brazil the cycle is called ciclo de receita. Its eight steps, including the denial and appeal loop, are covered in the Hospital revenue cycle guide. This guide asks a different question: what the US concept brings, and what has to change for it to work with Brazilian health plans (operadoras), the TISS standard and denial.
In practice, a hospital “does RCM” when patient access, authorization, clinical staff, audit, billing and finance answer for the same result, measured with standard KPI definitions, and every denial goes back to fix the step that caused it. RCM is not a synonym for software: systems support the work, but ownership, targets and payer contracts are hospital decisions. The difference from billing alone is covered in Revenue cycle vs hospital billing.
Where the term comes from: RCM was born in the US system
RCM took shape in the US, where hospitals bill public payers, such as Medicare and Medicaid, and private plans through electronic transactions standardized by law. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 led to mandatory standards for these exchanges [2].
According to the Centers for Medicare & Medicaid Services (CMS), the standards apply to health plans, clearinghouses and providers that conduct electronic transactions, not only those that accept Medicare or Medicaid [1]. The core transactions use ASC X12 Version 5010 [1]:
| Transaction | US standard [1] | What it does |
|---|---|---|
| Eligibility | X12 270/271 | Coverage and benefit inquiry and response |
| Authorization and referral | X12 278 | Service authorization request and response |
| Claim | X12 837 | Institutional, professional or dental claim |
| Claim status | X12 276/277 | Claim status inquiry and response |
| Payment and remittance | X12 835 | Payment and remittance advice |
Coding is standardized too: ICD-10-CM for diagnoses, ICD-10-PCS for inpatient procedures, CPT for outpatient procedures and physician services, and HCPCS for supplies not in CPT [1].
With standard processes and codes, the next step was standard measurement. The Healthcare Financial Management Association (HFMA) leads the MAP Keys: 29 revenue cycle benchmarking KPIs divided into five groups [3]. That combination of process, standard and KPI is what the market calls RCM.
RCM in the US vs Brazil: what changes?
The logic is the same; the environment is not. In Brazil, a private hospital's RCM revolves around saúde suplementar, the private health plan system. Health plans (operadoras), regulated by the ANS (Agência Nacional de Saúde Suplementar), are the main payer. At hospitals that belong to Anahp, the National Association of Private Hospitals, health plans accounted for 76.47% of gross revenue in 2025 [7].
| Aspect | United States | Brazil (private health plans) |
|---|---|---|
| Electronic exchange standard | HIPAA transactions in X12 5010 [1] | ANS TISS standard, RN 501/2022, in XML [4][5] |
| What must be electronic | Set by the transactions adopted under HIPAA [1] | Claims, payment and claim-review statements, denial appeals, admission and discharge notices; eligibility and authorization are optional [5] |
| Coding | ICD-10-CM, ICD-10-PCS, CPT, HCPCS [1] | TUSS terminology: tables 18 (daily rates and fees), 19 (supplies and OPME, i.e., implants and special materials), 20 (drugs), 22 (procedures) [5] |
| Reason for non-payment | Reported in the X12 835 remittance advice [1] | Denial reported in the claim-review statement with a TUSS table 38 code [5] |
| Payer-hospital rules | Contract with each payer | Mandatory written contract (Law 9,656/1998, art. 17-A) with minimum content set by RN 503/2022 [6][10] |
| KPI benchmarks | HFMA MAP Keys, 29 KPIs [3] | Anahp Observatório and Balanço reports; ANS denial indicator dashboard [7][8][9] |
Three differences matter most day to day:
Denial is line by line. In 2025, 58.6% of health plans' medical spending was paid fee for service, item by item [7]. In this model, each line of the claim is billed and can be denied separately: for the claims reviewed, the plan's remittance statement lists the denied lines [5]. An imported RCM model needs room for line-item appeals and negotiation.
The contract is regulated. RN 503/2022 (ANS Normative Resolution 503) requires the contract to set out the audit routine, the grounds for denial and the deadlines for contesting, responding and paying after reversal, with the contest deadline equal to the response deadline (art. 14) [6]. It also bars health plans from blocking access to denial justifications or the appeal itself, when billing follows the current TISS version (art. 5, V and VI, and sole paragraph) [6]. For RCM, the contract becomes a management tool, not just a commercial document.
One exchange standard that changes often. Instead of separate transactions, TISS has five components, each with its own version. In September 2026, the Organizational Component and TUSS were on version 202609 [5]. Tracking versions is ongoing RCM work in Brazil; see the TISS standard guide.
How RCM adapts to a Brazilian hospital
The most useful way to adapt the concept is to use HFMA's five KPI groups as a map and swap the content of each for its Brazilian equivalent [3].
View the diagram as a table
| HFMA group (US) | Brazilian hospital | Reference standard or rule |
|---|---|---|
| Patient Access | Eligibility and prior authorization | TISS (electronic optional) · RN 623/2024 |
| Pre-Billing | Documentation, account closing, internal audit | Medical record · discharge-to-submission time |
| Claims | Batch billing in XML | TISS (mandatory) · TUSS codes |
| Account Resolution | Denial, appeal, reconciliation | TUSS table 38 · RN 503/2022 |
| Financial Management | Revenue cycle KPIs | Anahp · ANS denial dashboard |
- Patient Access → eligibility and prior authorization. Confirm that the member is active and obtain the plan's authorization number. Electronic exchange for these steps is optional under TISS [5], and the plan's response to the member follows RN 623/2024 deadlines: up to 5 business days, or 10 for high-complexity procedures and elective admissions, with the shorter RN 566/2022 deadline prevailing where it applies [11]. See the Eligibility verification and Prior authorization guides.
- Pre-Billing → documentation, account closing and internal audit. What is not in the medical record does not go on the claim. The hospital controls all the time between discharge and submission.
- Claims → billing under TISS. Claim forms go out in XML batches, with TUSS codes and on the current version; electronic billing is mandatory [5].
- Account Resolution → denial, appeal and reconciliation. The plan returns a claim-review statement with the reason for each denial from table 38 [5]. The hospital appeals through TISS itself, within the deadlines the contract must set under RN 503/2022 [6]. See TISS denial codes and Denial appeals.
- Financial Management → revenue cycle KPIs. Initial and accepted denial, days to collect, collection rate and overdue receivables, using Anahp and ANS definitions.
Two pieces have no direct US equivalent and must be part of Brazilian RCM. The first is the payer contract: prices, annual adjustment and billing and payment deadlines are mandatory clauses under Law 9,656/1998, art. 17-A [10]. The second is the payment model: bundled (package) payments reached 13.1% of health plans' medical spending in 2025 [7], shifting part of the effort from line-item review to pricing. See RN 503/2022 and Hospital payment models. The split into front-end, middle and back-end is covered in Front-end, middle and back-end.
Which KPIs should Brazilian RCM track?
Brazilian RCM should track KPIs with a public benchmark and a known definition, so the hospital can compare itself with the sector without mixing denominators. The main ones come from Anahp and the ANS:
| KPI | Definition | Public benchmark |
|---|---|---|
| Initial denial | Amounts denied at first review ÷ amounts receivable from health plans (management figure, before negotiation) | 15.93% in 2025, Anahp hospitals [7][8] |
| Accepted denial | Denial the hospital did not contest or lost ÷ gross revenue from health plans | 1.72% in 2025, Anahp hospitals [7] |
| Days to collect | Days from invoice to payment | 77.35 days in 2025, Anahp hospitals [7] |
| Collection rate | Collected ÷ billed to health plans over the last 5 years | 88.61% in 2024, Anahp hospitals [8] |
| Overdue receivables | Invoices open more than 90 days ÷ average monthly billing over the last 12 months | 61.53% in 2024, Anahp hospitals [8] |
| Denial by health plan | Amount denied ÷ amount billed on closed claims | ANS denial indicator dashboard, by plan [9] |
Two cautions prevent bad comparisons. Anahp's initial and accepted denial use different denominators and cannot be divided by each other [7][8]. And a US KPI with the same name may use a different formula: check the definition at the source before comparing with a US benchmark. Full formulas are in Revenue cycle KPIs; the difference between denial types is in Initial, final and accepted denial.
What we see in operations
At Accrua, we treat the revenue cycle the way this guide describes it: one process, from patient intake to cash in the bank. From US-style RCM we keep the discipline of having a metric and an owner for each step. What changes in Brazil is the raw material: the TISS standard, TUSS table 38 and, above all, the contract with each health plan, which sets prices, deadlines and the grounds for a denial.
That is why Accrua OS runs on top of the HIS/ERP the hospital already uses and reads the whole claim before submission, for every health plan claim. Each item is checked against the contract, the current price table, the authorization rule and that health plan's denial history for that item. Agents handle what has a defined rule, such as XML validation, submission and remittance reconciliation. Anything that changes the value of a claim goes to a person.
When we read a hospital's history, we separate denials that are solved through appeals from those that have to be fixed at the source: registration, authorization, documentation. That split shows where the process needs to change.
Where to start
- Name an owner for the whole cycle, with authority over every area's targets.
- Map the five groups (access, pre-billing, claims, denial and appeals, financial management) and assign who answers for each.
- Adopt public definitions for initial denial, accepted denial and days to collect, with the denominator written down.
- Review contracts with the largest health plans against RN 503/2022: audit routine, denial grounds and appeal deadlines.
- Check the TISS version in use and name who tracks ANS releases.