eClinicalWorks’ revenue cycle management helps bridge the gap between a practice’s clinical and financial work. From registration and eligibility to claims, payments, patient balances, and reporting, eCW helps providers manage their practice’s billing. Providers can use eCW’s billing tools or outsource their billing through eCW’s managed services. Determining the right setup is vital by understanding how the technology works as well as the people who use the technology.
Some providers may find it difficult to manage collections, even when they are face-to-face with patients. Coding review may not have happened before a claim is submitted or a note is signed. A claim may not reach the payer. A payment may leave an unexplained balance. Knowing how and what to support is critical for practice owners in determining the root of the issue.
Separate the Platform From the Billing Service
eCW billing may mean different things to different people and provisions may vary. Before identifying gaps or comparing prices, confirm which of the eCW billing arrangements is being discussed.
In the in-house arrangement, your employees would manage the billing. Your staff would have to monitor submission exceptions, perform cash postings, and collections.
In eCW’s owned RCM arrangement, the vendor provides the billing and relies on the eCW technology to support the service. eCW provides managed service information in their published resources. Extra charges and the extent of the vendor’s responsibilities, exclusions, and escalation would require review of the contract.
Using eCW’s technology to support your chosen vendor is a different, separate arrangement from the eCW provider agreement. Having experience in using eCW’s technology doesn’t make a vendor eCW certified or an authorized partner.
A hybrid arrangement retains some functions with the practice and outsources others. Front desk staff may manage registration and communicate with patients, and a business partner may manage the follow up on claims and denials.
Begin with a responsibility map. Name the operator, reviewer, backup and person authorized to approve adjustments for each function. “Full service” is too ambiguous to tell if coding questions, old A/R, refunds, or patient calls, for example, are included.
eClinicalWorks Revenue Cycle Management in Daily Practice
The following is an illustrative operating model. The exact screens, work queues, integrations and permissions vary by eCW environment, and need to be confirmed. Align the workflow with your configuration, and ensure it is operational before briefing staff on the model.
1. Register the Patient and Verify Benefits
Review the patient’s ID and subscriber ID information to ensure they match. Check the member’s coverage and plan details to confirm the member is eligible for the visit, and review the benefits to determine if the plan covers the service.
Eligibility does not always mean the service is covered.
Appoint someone to resolve coverage issues before the encounter is billed. Having no subscriber information does not always indicate that the member is ineligible for services. Older information may still be helpful.
2. Resolve Financial Clearance
Determine who reviews and makes the authorization for visits, services and other specified restrictions. Define a person to review authorizations and approvals for planned changes in service.
When a claim has missing authorization, it is an authorization problem. Active coverage will not resolve an authorization problem. Likewise, authorization will not result in payment.
Discuss the patient’s expected financial responsibility with the information you have. Clearly identify an estimate from a final adjudicated amount. Ask for review of coverage rather than assume coverage and demand payment.
3. Reconcile Documentation, Codes, and Charges
Medical Coding Services should review whether every billed service corresponds to what the provider documented and performed. Each clinical encounter should contain a record demonstrating the provider’s basis for diagnosis and the reason for the visit, as well as the services rendered, including associated billing information.
Although modifiers and units vary by service, the documentation should be based on the service, and describe the service in enough detail to permit assignment of an ICD-10-CM or CPT code and a HCPCS code. Templates, coding tools, and checklists can help identify the service, but they do not prove that a service actually occurred or that it is worthy of separate reimbursement.
Sometimes staff may document and perform a service and yet fail to charge it, or charge it without sufficient documentation to support it. This situation can occur because of staffing constraints, time constraints, and/or a number of competing clinical priorities. A focused documentation query, answered by the appropriate clinician, can often address the issue. Assigning the query to the clinician provides better assurance that the cause will be addressed as opposed to repeatedly reassigning the same query to the billing staff.
Practices should test the EHR functions that facilitate specialty billing to determine if there are errors in documentation and charge rules associated with specialty billing (i.e. time-based services, injections, diagnostic tests and other specialty services). A cursory review of the EHR’s specialty billing features does not always ensure that the specialty services billing rules are configured correctly.
4. Scrub, Submit, and Confirm Receipt
Review the claim before releasing it. Verify the billing and rendering information, service location, relationship of the diagnosis to the service, units, and any documentation-dependent modifiers.
eClinicalWorks provides clearinghouse connections that support functions such as eligibility, claim edits, status, electronic remittance advices, and statements. Identify which connections and services your practice actually uses.
Track the status of claims beyond the initial “sent” status. For Medicare, CMS describes edits that occur prior to payment processing. Passing an initial edit does not mean the claim is payable.
Match released claims with the acknowledgments your connection returns. Check for missing responses and records that were rejected. Staff should know where to find clearinghouse receipts, payer acknowledgements, and the outcome of the subsequent adjudication.
5. Post Payments and Reconcile Deposits
An electronic remittance advice (ERA) explains how the payer processed claims, including payments and adjustments. Match the ERA to the corresponding electronic funds transfer (EFT) or check, then reconcile the payment with the bank deposit.
Remittances use Claim Adjustment Group Codes and Claim Adjustment Reason Codes (CARCs) for adjustments at the claim or service-line level. Group codes identify financial responsibility; CARCs explain the adjustment. Remittance Advice Remark Codes (RARCs) add detail or processing information. Provider-level adjustments appear separately in the Provider Level Balance (PLB) segment and use PLB reason codes.
Review exceptions to automated posting. If a remittance was not posted automatically, it may represent an unadjusted claim, or there may be an unexplained adjustment or payment. Never classify an unexplained difference as a contractual adjustment to close a batch.
6. Resolve Denials and Pursue Unpaid Claims
Before deciding on an action, assess the true status of the claim:
- Rejected: Identify the problem with the intake or claim edit, correct the information, and then resubmit.
- Denied: Read the explanation of the denial and take the most appropriate action, which may include correction, filing an appeal, requesting/submitting records to support the claim, etc.
- Accepted but unpaid: Determine whether payment was not made due to an outstanding request. Review the payer’s explanation to determine the status of the claim and proceed accordingly.
In Denial Management Services, one must assess the entire remittance before deciding on the course of action with respect to the denial claim. The denial description may be very brief and may have a relationship to another service line that has been covered within the claim. One must always keep the payer guidelines in mind when addressing issues like correction submission, record submission, and appeal.
While organizing the order of accounts receivable, age cannot be the sole criterion considered. Other criteria that must also be kept in mind include: deadline of the payer, allowable amount expected, chances of recovery, documentation needed, next step, and what has been reviewed so far.
7. Bill Patients From Validated Balances
Be certain payer adjudication, secondary coverage, patient deposits, and payments have been applied prior to issuing a patient statement. Check that the patient is, in fact, responsible for the remaining balance under the rules and agreements.
A zero payment by an insurer does not automatically create patient debt. On a Medicare remittance, CO (Contractual Obligations) amounts are provider liability and must not be billed to the patient. Only amounts assigned to PR (Patient Responsibility) may be considered for patient billing, after secondary coverage, prior payments, and applicable beneficiary protections are checked. Do not transfer a CO amount to the patient to clear an unpaid claim.
Patient responsibility balances need to be visible to the team responsible for collection in order to close the loop on the account. Provide a pathway for questions and corrections to balance statements, and make available payment plans and arrangements.
Automate balances only when the underlying obligation is certain.
8. Close the Loop with Financial Reconciliation
Reconcile all work. Explain uncollected balances. Distinguish the difference between an adjustment and a loss. Track and reconcile refunds and credits. A collection opportunity is not the only reason an account needs to be worked.
Define who has authorization to post adjustments and who reviews unusual or questionable transactions and balances. This provides the practice with control of its financial health, as opposed to relying on a dashboard that is balanced due to unresolved differences being written off.
Designate an Accountable Owner for Each Work Queue
Organize tasks according to the problem and action required to resolve it. A good work item should include the account, amount, claim state, blocking issue, evidence, assigned owner, next action, and follow-up point.
Do not route all unpaid claims to the same generic bucket. A missing clinical detail should be with the clinician and/or coding reviewer. A payer enrollment mismatch should be reviewed by enrollment or contracting. An unexplained posting difference should be reviewed by payment reconciliation.
For payment review, compare the amount paid with the expected payer payment after valid patient responsibility and applicable payment adjustments. If the payer owes $100 under the contract but pays $80, investigate the $20 difference using the remittance, billed codes, modifiers, units, and contract terms. If $100 remains supported, assign a correction request or appeal with the evidence and deadline. Update the expectation only when the contract or payment rules support a different amount, rather than lowering it to match the payment received. Do not shift a disputed payer underpayment to the patient.
Verify there is progress being made. Repeated calls for the same next step to be taken should be reviewed to ensure there was a blocked issue or if an investigation was completed. Small queues of unresolved documentation requests can be more important than larger queues of requests being routinely reviewed.
Turn eClinicalWorks Reporting Into Assigned Action
eClinicalWorks Business Optimizer (eBO) provides reporting capabilities for financial, clinical and administrative data. Reporting capabilities may include A/R and claim transaction reports, denial reports, payer mix, productivity and other reports. Confirm availability and access of reports for your site.
Prior to utilizing a report, validate a sample against source accounts. Ensure that you are clear about the report’s date filter. It may use the service, posting, submission or payment date. Also, confirm the meaning of the provider field, i.e. rendering, billing or other.
Confirm aging basis and determine whether credits, unbilled encounters, patient balances, and outsourced accounts are included. Two reports can both be accurate but address different questions.
Use a reasonable review frequency based on your business needs:
- Daily: Submission exceptions, missing acknowledgments, encounter holds, unposted remittances, deposit differences, etc.
- Weekly: Denial causes, outstanding payer collection deadlines, high A/R, unresolved queries, reassigned tasks, etc.
- Monthly: Collections, adjustment categories, aging movement, payer trends, refunds, contract-to-payment differences, etc.
These management practices are not payer requirements. Adjust to your business needs and staffing levels.
After each review, determine what the next step will be, including who will be responsible for completing it, the accounts affected, and the evidence required to verify completion. If a report reflects the same observation repeatedly, investigate whether the assigned action was completed.
Find the Gap Behind Unpaid Claims
Begin by looking at a sample of encounters, claims, and payments. A workflow analysis will point you to the breakdown in the process, what data is missing, and what party needs to take responsibility.
Measure Performance With Consistent Definitions
A useful eClinicalWorks revenue cycle management dashboard connects measures to decisions. Agree on definitions before comparing teams, payers, or service partners. HFMA’s MAP Keys provide published methods for measures including charge lag, clean claim rate, remittance denial rate, and net days in A/R.
|
Measure |
Calculation basis |
Practical use |
|
Charge lag |
Sum of days from service to initial charge posting ÷ number of charges. |
Investigate documentation or charge-entry delays. |
|
Clean claim rate |
Claims passing processing edits without manual intervention ÷ claims entering that processing tool × 100. |
Identify recurring data and edit problems. |
|
First-pass acceptance |
Original claims accepted at a defined checkpoint ÷ original claims submitted there × 100. |
Assess transmission quality; name the clearinghouse or payer checkpoint. |
|
Remittance denial rate |
Actionable claim-level denials ÷ remitted claims × 100, applying documented inclusion and exclusion rules. |
Identify payer and root-cause patterns. |
|
Net days in A/R |
Net patient A/R ÷ average daily net patient service revenue. |
Assess outstanding receivables on a consistent net basis. |
|
Adjusted collection rate |
Payments net of credits ÷ charges net of approved contractual adjustments × 100. |
Compare collections with collectible revenue. |
The adjusted collection formula follows AAFP guidance. Align payments with the associated charges when assessing collection performance. Separately identify preventable losses rather than hiding them within contractual adjustments.
First-pass acceptance and first-pass resolution answer different questions. Acceptance concerns a defined intake checkpoint. For a resolution measure, document which final outcomes count and whether further intervention was required.
Avoid comparing a net-revenue-based A/R measure with a gross-charge-based version. Likewise, claim-level denials should not be compared directly with line-level counts.
Review older balances as well as the overall A/R measure. Set improvement goals against your own baseline and genuinely comparable practices; an isolated percentage rarely explains the underlying problem.
Automation with Clear Review Rules
The vendor provides information on automated RCM functions that include code recommendations, eligibility interpretations, appeal preparation, and workflow rules. Verify availability, configuration, permissions, and service scope, to determine if a feature is included in your contract.
Define review rules for each automated function. The system may be able to perform a given function, but there may be exceptions. For instance, the system may recommend a code but may still require a review to ensure that the code is appropriate. An appeal packet may be assembled but it still may need to be reviewed to ensure that it includes the correct claim and appeal argument. A posting rule needs a way to flag unexplained differences.
Test changes against variety of cases before generalizing them. Consider atypical cases such as secondary coverage, corrected claims, credit balances, and partial payments. Keep a procedure to escalate when output does not match expected value.
Assess automation through results that can be clearly observed, for example, if exception processings and follow-up tasks are completed, or claim was posted correctly and claim disposition is corrected. A decrease in clicks or increase in task completion rate do not necessarily result in better financial performance.
Compare Billing Models and the Complete Cost
The right billing model depends on the work your practice can reliably supervise and complete. Compare equivalent scopes rather than headline percentages.
|
Decision factor |
In-house billing |
eClinicalWorks RCM service |
Independent partner or hybrid |
|
Day-to-day staffing |
Practice recruits, trains, and covers absences. |
Responsibilities follow the vendor agreement. |
Responsibilities follow the partner’s statement of work. |
|
Workflow control |
Direct control, with internal supervision required. |
Confirm change requests and escalation ownership. |
Specify retained duties and approval authority. |
|
Financial visibility |
Practice maintains reports and review routines. |
Demonstrate included reports and account access. |
Require agreed reporting and account-level work visibility. |
|
Legacy A/R |
Internal team allocates capacity. |
Confirm inclusion and exclusions. |
Define inventory, fees, and transition boundaries. |
|
Total cost |
Include labor, supervision, coverage, tools, and rework. |
Confirm pricing basis and additional charges. |
Include retained practice work and all extra fees. |
|
Exit responsibilities |
Preserve documentation and continuity internally. |
Review access and handover terms. |
Agree on open claims, notes, balances, and access removal. |
For a percentage-based proposal, establish which collections enter the fee calculation. Ask about patient payments, old A/R recoveries, refunds, reversals, and services retained by the practice.
The vendor’s published pricing distinguishes service plans and identifies additional charges for certain activities. Obtain an itemized proposal for your circumstances rather than treating a listed rate as the complete cost.
Request a demonstration using representative billing problems. Ask the proposed team to explain how it would investigate an accepted-but-unpaid claim, an unmatched remittance, and a documentation hold. An anonymized work sample is more useful than an unsupported promise of higher collections.
Separate workflow gains from unrelated changes in volume, payer mix, fee schedules, and clinician availability when evaluating results.
Protect Access and Plan the Handoff
When a practice outsources
The HIPAA Security Rule requires unique user identification under 45 CFR 164.312(a)(2)(i). Assign each person who accesses systems containing electronic PHI a unique user ID so access and activity can be traced to that individual. Shared logins do not meet this requirement. Limit permissions to the user’s role and remove access promptly when duties change or the relationship ends.
All open claims and credits, unapplied payments and refund requests, pending patient refunds and refund disputes, patient collections and related follow-ups, and disputed claims should be documented before the transfer of work. Assign an owner to each of these items. The same is true for tasks assigned to the billing staff.
The agreement should delineate boundaries for the staff including, but not limited to, approved methods of communication, financial limits, and write-offs. The staff needs to be made aware of billing system access and related limits.
The billing and collections process should be demonstrated on a limited number of accounts to start, and expanded to additional accounts once the billing team has the ability to locate supporting records to validate claim actions and prepare required reports.
Review the Workflow Before Switching Providers
Trace each account from the time it was encountered until it reaches its current financial disposition. Start with a sampling of different providers and payers, locations and claim states. Once you can no longer identify a handoff, document it, and report it to the individual that can provide an explanation.
There are numerous possibilities for the cause of the issues uncovered, including insufficient documentation, configuration, and staffing, as well as payer and reconciliation issues. It is possible that a partnering billing entity can assist in determining the cause for the issues, however, an unresolved query by a clinician or an uncorrected Payer enrollment record remain the responsibility of the owning entity.
Use the evidence to determine the next course of action. Possible options include training, configuration changes, temporary A/R outsourcing, broad scope changes to the operating model, or defining outsourcing. Comparing potential solutions to the problem is facilitated when a specific problem statement is created.
Billing Support to Suit Your Practice
Bring up all of your workflow, report generation, and division of labor problems at a billing support consultation meeting. Identify the scope, proof, escalation process, and money control methods to determine if changes within your organization, help, or outsourcing are right for your practice.
Frequently Asked Questions
What does eClinicalWorks revenue cycle management include?
It can encompass registration, benefit checks, charge capture, coding review, claims, payment posting, denials, A/R follow-up, patient billing, and reporting. The division of work depends on your software configuration and service agreement. Confirm the assigned responsibilities instead of assuming every function is included in one package.
Can a practice use eCW without outsourcing billing?
Yes. The platform supports a self-service model in which the practice manages billing with its own team. That arrangement requires trained staff, backup coverage, supervision, and dependable exception handling. Compare those operating requirements with managed services or a hybrid arrangement before choosing a model.
Does eClinicalWorks automatically prevent claim denials?
No system can guarantee that every claim will be paid. Claim edits and eligibility tools can help identify certain issues, while reimbursement also depends on documentation, coverage, authorization when required, enrollment, and payer adjudication. Staff still need to review exceptions, investigate denials, and act on unpaid claims.
Can an independent billing company work with eClinicalWorks?
A suitable independent company may work through authorized access or an approved integration, subject to the practice’s agreements and technical setup. Verify its proposed access, duties, reporting, and safeguards. Experience using eCW alone does not establish an official relationship with the software vendor or coverage of every billing task.
Which eCW reports are useful for billing oversight?
Prioritize information about unbilled work, submission exceptions, denials, A/R aging, payment posting, adjustments, and payer performance. eBO offers financial and administrative reporting capabilities, but confirm the actual reports available to your practice. Validate filters and sample transactions before using the output to assess staff or partner performance.
Is a high claim acceptance rate proof of strong collections?
No. Acceptance indicates that a claim passed a defined intake checkpoint. It does not establish correct payment, successful appeals, or collection of legitimate patient responsibility. Review adjudication, outstanding balances, adjustments, collection performance, and reconciliation alongside acceptance. Define the checkpoint before comparing acceptance figures across systems or service partners.
Select Support with Clear Accountability
EClinicalWorks revenue cycle management will work successfully with precise documentation, proper transfer, and tasks completed to achieve a comprehensible result. The ideal system should be understandable, manageable, and measurable by your office.
