Hospital & facility billing
Complex Encounters Need Connected Billing Workflows
Hospital and facility billing can involve patient access, authorization, clinical documentation, charge capture, coding, claim validation, records requests, payer processing and follow-up. Kitronixe supports these workflows within the agreed scope so outstanding work remains visible from encounter through resolution.
Patient access
- 8Registrations to correct
- 14Authorizations pending
Encounter & charges
- 19Documentation pending
- 11Charge review
- 16Coding review
Claims
- 142In claim production
- 6Records requests
Payer & follow-up
- 23Denials
- $218.4KPayments posted
- $1.24MOutstanding A/R
Illustrative data for a fictional facility: counts of encounters or claims, and dollar amounts where marked. Not a Kitronixe result or a client’s figures.
More hands, more hand-offs
A facility encounter passes through more departments than most claims
A facility encounter passes through more hands than most claims: registration, authorization, the clinical team, charge capture, coding and the billing office. Each hand-off is a place where work can wait without anyone seeing it.
Kitronixe supports the billing workflow across those hand-offs, within the scope agreed for each engagement - keeping each outstanding item visible, with an owner and a next step, from the encounter to resolution.
Hospital revenue journey
Four departments, twelve stages, and the hand-offs between them
- Patient access
- Clinical / charge
- Claim
- Payer / follow-up
Patient access
Registration
Patient and insurance details captured at access.
Patient access
- 01
Registration
Patient and insurance details captured at access.
- 02
Eligibility
Coverage confirmed for the encounter.
- 03
Authorization
Authorization requirements identified and coordinated where applicable.
Clinical / charge
- 04
Encounter
The patient is seen; the facility encounter begins.
- 05
Documentation
Clinical documentation completed by the care team.
- 06
Charge Capture
Facility charges captured from the encounter.
- 07
Coding
Coding coordinated based on documentation, within the agreed scope.
Claim
- 08
Claim Validation
The claim checked against payer and format requirements.
- 09
Submission
The claim is submitted and tracked.
Payer / follow-up
- 10
Payer Processing
The payer adjudicates and responds.
- 11
Payment / Denial
Payment posted and reconciled, or a denial categorized.
- 12
A/R Follow-Up
Anything unresolved followed up to a close.
Facility and professional billing
One patient encounter, different billing workflows
Facility / institutional billing
The hospital or facility’s own services
- Facility services
- Institutional claim workflow
- Facility charges
- Applicable revenue and service information
One patient encounter
Different billing workflows
Professional billing
The physicians’ and providers’ services
- Physician and provider services
- Professional-fee claim workflow
- Provider documentation
- Professional coding workflow
Not every encounter generates both. What actually gets billed depends on:
- Services performed
- Provider arrangement
- Place of service
- Payer
- Organizational structure
Institutional and professional claims use different formats and workflows. This is an explanation, not coding guidance.
The claim control board
Every facility work queue, by phase of the cycle
Facility claim control board
Work queues by phase of the cycle
Authorization missing9
Needs attention
e.g. Encounter 1042 · Payer B
Authorization workflow
Registration correction8
e.g. Encounter 1057 · Payer A
Demographic correction
Eligibility issue5
e.g. Encounter 1061 · Payer D
Re-verify coverage
Showing Front-end queues.
Illustrative workflow: invented queue counts and encounters, identified by number, with payers shown as letters. No patient information; not a Kitronixe result.
Encounter handoff map
Where hospital billing can stall - and where the work goes next
Stall point 1
Registration issue
Eligibility or demographic correction before the claim is built.
Stall point 2
Authorization issue
Payer and authorization workflow, within the agreed scope.
Stall point 3
Incomplete documentation
Billing hold and review until the documentation is complete.
Stall point 4
Charge issue
Charge review with the responsible department.
Stall point 5
Claim edit
Correction before submission.
Stall point 6
Records request
Documentation submission, tracked to a response.
Stall point 7
Denial
Denial workflow - worked by cause.
Stall point 8
Unresolved balance
A/R follow-up by priority.
Care settings
Different settings, different billing considerations
Inpatient
An admitted stay, billed by the facility; professional services are billed separately.
Outpatient hospital
Hospital-based services for patients who are not admitted.
Observation
A status with its own documentation and payer rules, distinct from admission.
Emergency department
Emergency encounters, with facility and professional components.
Hospital-based professional
Physician services in the hospital - billed as professional claims, where scoped.
What is covered
Hospital billing capabilities, within the agreed scope
Patient access & facility workflow
Patient-access billing workflow
Registration details that billing depends on, reviewed and corrected.
Eligibility
Coverage verified for the encounter where payer systems allow.
Authorization coordination
Authorization requirements coordinated where within the agreed scope.
Facility billing workflow
The facility claim followed from encounter to resolution.
Charges, coding & claims
Charge-capture workflow
Facility charges captured and reviewed with the responsible departments.
Documentation follow-up
Incomplete documentation that holds billing followed up with the care team.
Coding coordination
Coding coordinated based on documentation, within the agreed scope.
Claim validation
Claims checked against payer and format requirements before submission.
Institutional claim workflow
Institutional claim preparation where applicable to the engagement.
Electronic claim submission
Claims submitted electronically where the payer accepts them.
Payer response
Rejections
Rejections corrected and resubmitted.
Denials
Denials worked by cause, with the pattern reported back.
Medical-record requests
Payer requests for records tracked, answered and followed.
Payment posting
Payments and adjustments posted accurately.
Payments, A/R & reporting
Reconciliation
Remittances reconciled against what was billed and expected.
A/R follow-up
Open facility claims worked by priority.
Payer follow-up
Claims followed up with payers, with each action recorded.
Reporting
Claims, denials, requests, payments and A/R, reported regularly.
Reporting
Reported by status, payer, age and department
- Claims by statusClaim
- Claims by payerClaim
- DenialsPayer / follow-up
- Records requestsClaim
- Payment activityPayer / follow-up
- Outstanding A/RPayer / follow-up
- A/R by agePayer / follow-up
- A/R by payerPayer / follow-up
- Outstanding documentationClinical / charge
- Outstanding work queuesPatient access
Where this sits
Hospital Billing, Physician Billing and RCM
Hospital BillingThis page
The facility’s billing workflow, within the agreed scope - from access to A/R.
Physician Billing
Professional-fee billing for the providers, available separately.
Revenue Cycle Management
The complete, connected revenue-cycle operating model.
Why Kitronixe
How Kitronixe supports facility billing
Hand-offs made visible
Every item waiting between departments has an owner and a next step.
Scoped honestly
We support the facility billing workflow within the agreed scope, and say plainly what is outside it.
Professional billing kept distinct
Physician and provider billing is available separately, so the two workflows are never confused.
Records requests handled
Requests are tracked to a response so claims do not stall.
Denials worked by cause
Each denial goes to the workflow that fixes it.
Reporting you can act on
Claims, denials, requests and A/R reported by status, payer and age.
What is hospital billing?
Hospital billing - also called facility billing - is billing for the facility’s own services: the setting, equipment, supplies and staff involved in an encounter. It uses its own claim workflow, separate from the professional billing for the physicians involved.
How is facility billing different from physician billing?
Facility billing covers the hospital or facility’s services; physician billing covers the professional services of the providers. A single encounter may involve one or both, depending on the services performed, the provider arrangement, the setting and the payer.
Can Kitronixe support institutional claim workflows?
Yes, where they are part of the agreed scope. Institutional claims have their own format and requirements, and the workflow is set up for them specifically.
Can you help with hospital A/R?
Yes. Open facility claims are prioritized by status, payer response, filing and appeal limits, balance and age, and followed up. No outcome can be guaranteed.
Can you support denied facility claims?
Yes. Denials are worked by cause - corrected, appealed where appropriate, or closed with a reason - and the pattern is reported back.
Can you help with medical-record requests?
Yes. Payer requests are tracked, the documentation is gathered from the responsible department and sent, and the claim is followed until the payer responds.
Can you support outpatient hospital billing?
Outpatient hospital services can be part of the scope. The billing workflow depends on the services, the setting and the payer.
Do you provide professional billing separately?
Yes. Physician and provider billing is available separately as Physician Billing, and can be scoped alongside facility billing or on its own.
Can you provide hospital billing reports?
Yes. Reporting can show claims by status and payer, denials, records requests, payment activity, A/R by age and payer, outstanding documentation and outstanding work queues.
Can Hospital Billing be scoped separately from full RCM?
Yes. Hospital Billing can be scoped on its own, or as part of a wider revenue-cycle engagement.
Talk through your facility billing workflow
Tell us where facility claims wait today. We will be clear about what is within scope and where to start.