How to Assess a Revenue Cycle Management (RCM) System: The Hidden Costs of Incomplete Payer Coverage
In the increasingly automated world of healthcare operations, not all revenue cycle management (RCM) systems are created equal. One of the most critical—yet often overlooked—criteria for assessing an RCM solution is payer coverage. That is, can the system actually handle the full lifecycle of claims for all your patients, across all your payers?
The reality is that many systems claim automation but fall short when it matters most: when payer-specific workflows become complex, when attachments are required, or when eligibility responses are nuanced. This blog explores the full depth of that issue, why it costs more than you think, and how a layered fallback approach can preserve both revenue and patient trust.
Why Payer Coverage Matters
Let’s break it down: every RCM system interfaces with a mix of patient, provider, and payer data. But not every RCM can handle every transaction type—especially across every payer. For example:
Eligibility Checks (270/271)
Attachment Submission
Claim Filing (837)
Payment and EOB Processing (835)
Some payers might not support direct EDI integration. Others may offer poor documentation or outdated portals. If your system doesn't support a specific payer for a required transaction, the task either fails silently, or worse, falls to a human fallback.
The Real Cost of Human Fallbacks
When automation fails, staff must intervene manually. This can involve:
Navigating complex payer websites
Logging into practice management or imaging systems
Gathering documentation and preparing resubmissions
Calling the payer—often waiting on hold for 30 minutes or more
This work can take 30–90 minutes per claim, depending on the complexity. At a labor cost of $20–$60 per hour, that’s $30–$90 to recover a single $200 claim.
Multiply that by just 5 one-off claims per day, and suddenly you're leaking thousands per month. This also diverts attention away from other high-value tasks like claim optimization, appeal strategy, and patient engagement.
Patient Relationship Risk: The Cost of Inaccuracy
A weak RCM system doesn’t just drain revenue—it can erode trust.
One example: Coordination of Benefits (COB). If your RCM’s eligibility logic or payment posting doesn’t correctly interpret COBs, you might:
Send inaccurate patient estimates
Submit secondary EOBs with PHI from unrelated patients
Miscalculate patient balances
These mistakes aren’t just operational—they’re relational. If you tell a patient their visit will cost $40 and later send them a $120 bill, you’ve broken their trust. Even if the insurance company is to blame, the patient blames you.
Studies show that patients respond much more positively when told an accurate, even if higher, cost up front. That transparency helps preserve long-term relationships.
The Sensitivity of Write-Offs
Another friction point is write-offs. If your system misidentifies contractual adjustments or applies them incorrectly, you may:
Undermine revenue targets
Disrupt collections tracking
Overlook underpayments from payers
While write-offs are a normal part of healthcare finance, they must be calculated accurately and transparently. Overuse or misclassification can make a practice appear unprofitable—and leave revenue on the table.
Secondary EOBs: A Case Study in System Quality
Take secondary EOB processing. For large DSOs, a single EOB PDF might contain dozens of patients. A high-quality RCM platform must:
De-identify unrelated patients' information
Extract only the relevant patient’s data
Format it cleanly for re-submission
If your AI fails here, you’re again sending staff to correct it manually—or risking HIPAA violations. A robust system doesn't just submit claims—it prepares, filters, and contextualizes them to meet payer and compliance standards.
How Curaclear Solves This Problem
At Curaclear, we address these challenges head-on with a multi-layered fallback system. When automation fails, we don’t just hand it off to a staff member—we escalate it through a series of intelligent pathways:
Redundant submission protocols for edge-case payers
Deep eligibility interpretation across payer websites and EDI
Context-aware document generation for attachments and appeals
Live agent escalation, including payer calls when necessary
We also respect web blockers and automation limits, using ethical, secure techniques that stay within compliance. Our systems are built to handle exceptions intelligently—not just pass them off.
Final Thoughts: Assess Your RCM Like You’d Assess a Staff Member
Would you hire an employee who can only handle 80% of the job? Probably not. So why tolerate an RCM system that automates only the easy stuff?
When assessing a revenue cycle platform, ask:
Does it handle all your payers, or just the common ones?
Can it process secondary claims and COB logic reliably?
Does it offer fallback strategies beyond “assign it to staff”?
How does it ensure patient estimate accuracy?
Your RCM should maximize revenue, minimize staff fatigue, and enhance patient trust—not trade one for the other.
Curaclear is your Large Language Model business partner in navigating these complexities—so you can focus on patient care, not paperwork.
Want to learn more? Contact us or schedule a demo to see how we handle what others can’t.