RevCycleMGMT engineers audit-defensible RCM platforms that unify EHR clinical documentation, 837/835 EDI streams, and contract logic into a single, validated source of truth. Our pipelines natively process X12 and FHIR standards, enforcing automated quality gates so every revenue metric (Clean Claim Rate, DNFB, Net Collection Ratio) is directly traceable to source evidence for RAC, TPE, and commercial payer audits.
RevCycleMGMT’s pipeline ingests and reconciles 837/835 EDI streams, enforcing strict ISA/GS/ST validation and 999/277CA tracking to normalize data into a governed canonical schema (claims_header, adjudication, payments). Our Denials Intelligence engine translates CARC/RARC codes into actionable root causes, feeding executive dashboards for First Pass Clean Claim Rate (FPCCR), payer lag, and A/R rollups. Engineered for HIPAA compliance with PHI-segregated logging, we provide deterministic lineage from raw EDI to financial metric—equipping revenue teams with the speed and forensic proof needed for audit defense.
Predict revenue leakage before the claim is even submitted. RevCycleMGMT’s intelligence engine transforms 837/835 patterns and clinical documentation into calibrated denial risk scores with transparent explainability. We benchmark payer behavior against contract terms to surface underpayments and audit triggers in real-time. Eliminate avoidable write-offs, focus revenue integrity teams on high-yield appeals, and maintain a forensic data trail that stands up to CMS RAC and commercial payer scrutiny.
RevCycleMGMT’s compliance engine is built on HCCP (Healthcare Compliance Certification Program) standards to ensure your documentation withstands scrutiny. We automatically validate HCC (Hierarchical Condition Category) codes against your clinical notes to prevent “upcoding” risks while identifying legitimate revenue opportunities you might have missed.
Instead of manual chart reviews, you get a real-time scorecard showing exactly which charts need attention to meet CMS and HIPPA requirements. It’s not just about getting paid—it’s about keeping what you earn without fear of an audit.
RevCycleMGMT teams with Federal Primes to execute high-stakes CMS Program Integrity and Fraud, Waste, & Abuse (FWA) audits. We provide the forensic data analytics required to identify improper payments within Medicare & Medicaid populations, ensuring every finding is backed by OIG-standard evidence.
We are Procurement-Ready (SAM.gov UEI G1RAMD6SHKZ1, CAGE 13N38) and certified Metro SBE/DBE (CUCP #53388). Whether supporting a UPIC (Unified Program Integrity Contractor) or RAC (Recovery Audit Contractor) workflow, we deliver the specialized clinical data expertise Primes need to win and execute.
RevCycleMGMT provides healthcare revenue cycle management (RCM) technology and data analytics. Our platform, including all AI-driven insights, scorecards, and audit evidence, is for administrative and informational purposes only. We are not a law firm, and our software does not constitute legal counsel regarding CMS regulations or anti-kickback statutes. Furthermore, our clinical coding suggestions do not constitute medical advice or practice of medicine. The ultimate responsibility for patient care and clinical documentation resides solely with the licensed provider.
While RevCycleMGMT utilizes industry-standard rules (including NCCI edits, LCDs, and HCCP standards) to identify compliance risks, we do not guarantee specific financial outcomes, audit results, or the prevention of payer clawbacks. Payer policies and government regulations are subject to change without notice. RevCycleMGMT shall not be held liable for any denied claims, fines, or penalties incurred by the user. All "Risk Scores" and "Win Probabilities" are probabilistic estimates based on historical data, not guarantees of future performance.
