GoMedPay Education Series

What is Revenue Cycle Management?

RCM is the complete financial process that begins the moment a patient walks in and ends only when every rand earned has been collected. Most South African practices are unknowingly losing 15–25% of revenue somewhere in this chain.

The South African context

RCM is standard in the USA. In South Africa, it barely has a name.

In the United States, every hospital system has a dedicated Revenue Cycle department. In South Africa, the equivalent function is split between the doctor, a billing company, a switch (Healthbridge, GoodX, or Altron), and the medical aid — with no single party accountable for the full chain.

The result: valid claims expire at 120 days. Silent underpayments are never disputed. COIDA and RAF receivables sit in the general debtors ledger for years. GoMedPay applies AMA 9-step RCM methodology — adapted for the SA Medical Schemes Act environment.

120
Days before a claim becomes irrecoverable under Regulation 6
90
Days before the medical aid dispute window closes
25%
Typical uncollected revenue in an unmanaged specialist practice

The Revenue Cycle: Five Stages, Three Leak Points

Every consultation starts a chain of events. Most practices assume the chain is intact. GoMedPay checks every link.

Patient consultation Revenue earned at this point Submitted to switch Healthbridge · GoodX · Altron Stale claim trap 120-day cliff — R0 recovery Medical aid adjudicates Discovery · GEMS · Momentum ICD-10 / PMB coding gap Patient bears the shortfall ERA returned to practice Payments and rejections Silent underpayment 90-day dispute window closes Cash received at bank Revenue cycle complete GoMedPay closes all three gaps — AMA 9-step RCM framework adapted for SA

The 9-Step RCM Framework — SA Edition

Based on the AMA Revenue Cycle framework, adapted for the Medical Schemes Act, Regulation 6, and the South African switch environment.

Step 1
Patient Registration & Eligibility

Verify medical aid membership, plan option, and dependant code before treatment. A wrong dependant code causes 100% rejection at adjudication.

Step 2
Pre-Authorisation

Obtain scheme authorisation for all prescribed procedures. No authorisation number = no payment for most in-hospital events.

Step 3
Clinical Documentation & Coding

ICD-10 codes must match the clinical record. PMB coding errors shift liability from the scheme to the patient — legally and financially.

Step 4
Charge Capture

All procedures, consumables, and modifiers must be captured before the claim is submitted. Missed charges are permanently lost.

Step 5
Claim Submission via Switch

Electronic submission through Healthbridge, GoodX, or Altron. The 120-day Regulation 6 clock starts from date of service — not date of submission.

Step 6
Adjudication Monitoring

Track ERA (Electronic Remittance Advice) from Discovery, GEMS, Momentum et al. Every rejection must be categorised and actioned within the dispute window.

Step 7
Denial Management

SA schemes issue soft denials (pend) and hard denials (reject). Each requires a different response — clinical motivation vs. resubmission vs. Section 59(2) dispute.

Step 8
Patient Liability Collection

Patient shortfalls, co-payments, and self-pay balances require a separate collection workflow. The Collection Covenant framework governs patient communication under GoMedPay.

Step 9
Reporting & Analytics

Every practice should answer six questions daily: What did we earn? What was billed? What was rejected? What was paid? What is stuck? What must be followed up today?

SA-specific note: The AMA framework assumes a US payer environment. GoMedPay's SA adaptation incorporates Regulation 6 of the Medical Schemes Act (120-day cliff), Section 59(2) dispute rights, HPCSA coding rules, and COIDA/RAF as separate long-cycle asset classes — none of which exist in the US system.

Who Owns the Cycle in a South African Private Practice?

The Doctor (MD/Owner)

Sets the clinical standard, signs off coding decisions, carries the ultimate financial risk.

Practice Manager

Manages the day-to-day submission, follow-up, and collections workflow.

Billing Company / Switch

Submits claims electronically. Does not chase denials or manage cash collections.

GoMedPay

The accountable layer across all nine steps — from registration through to cash received at bank.

How GoMedPay Closes the Gaps

Get paid what you billed

Recover the revenue that medical aids reject, short-pay, or quietly leave behind.

  • We classify every rejected and short-paid claim by cause: coding/tariff mismatch, eligibility, authorisation, documentation, duplicate, or PMB shortfall.
  • We pursue what is recoverable inside the Medical Schemes Regulations windows — 60 days to correct and resubmit a queried claim, before the ~120-day submission cliff.
  • PMB shortfalls are surfaced specifically: where a scheme is legally obliged to fund in full but paid from savings or short-paid.

Defensible billing (Section 59 readiness)

Keep a clean, documented billing trail so legitimate claims can be explained when a scheme asks.

  • We help your team store authorisations, link clinical justification to billed codes, and log every correction and resubmission.
  • We focus on high-value, repeated, or unusual claims — the patterns scheme analytics flag.
  • GoMedPay improves billing evidence and controls. We do not provide legal advice and cannot prevent or stop a Section 59 investigation.

Recover aged balances under your brand

The disciplined step before debt collection — not debt collection.

  • We classify aged balances: recoverable scheme balance, scheme short-payment, patient shortfall, unmatched receipt, write-off, and COID / long-cycle.
  • We act on the recoverable and reconcile receipts to the bank.
  • All patient communication carries your practice's name. Patients never see GoMedPay.

Find Out Where Your Practice's Cycle Is Leaking

An Unpaid Claims Review maps your practice against all 9 steps — with rand-value exposure at each gap.

Book an Unpaid Claims Review
RCM Knowledge Centre → COIDA & RAF Claims →