Roles of the Revenue Cycle Management Team Members – Front Desk, Provider, and Biller

In a pediatric practice, the Revenue Cycle Management (RCM) process is more than just billing—it’s a collaborative system that starts the moment a patient schedules an appointment and ends when the payment is received. Every team member plays a critical role, and understanding these roles is essential to improving cash flow, reducing denials, and enhancing patient satisfaction.
Let’s break down the three core players in your RCM team: the Front Desk, the Provider, and the Biller—and how each contributes to your practice’s financial health.
1. Front Desk: The Gatekeepers of Clean Claims
The front desk team is often the first point of contact and the first line of defense in revenue cycle success. Their responsibilities include:
Insurance Verification: Ensuring coverage is active and up to date before the visit. Consistency on insurance verification is a critical factor in the revenue cycle. A front desk team member should be following a consistent check in process for patients. This includes verifying all patients are ‘eligible’ via the system eligibility tool and manually checking all patients that show as either ‘not eligible’ or ‘unknown eligibility’. For all patients that show as “not eligible” or ‘unknown eligibility’ the front desk needs to verify the insurance via the payor provider portal. Front desk team members should be logged in to the payer provider portals first thing in the morning and all day to confirm each patient’s insurance is eligible at the time of service. If they can not confirm eligibility with the insurance, they should either make the patient ‘self pay’ or obtain new insurance when the parent checks in. Practices that see patients whose insurance is not eligible experience much lower collection rates than practices that are consistent on this process. Consistent training and monitoring of this task is an important role of the practice leader/owner.

Accurate Data Entry: Correct demographic and insurance information minimizes claim rejections. The entry of patient demographics and insurance details is an important task of the front desk team. Once entered correctly, the insurance should show as ‘eligible’ in the system. If the insurance shows are ‘unknown eligibility’ or ‘ineligible’, the front desk team member needs to verify the demographic and insurance details match the data in the insurance database. They can complete this task via the provider payer portal.

Collection of Copays/Deductibles and co-insurance: Promptly collecting patient responsibility at the time of service. The account displays the copay for sick visits and the front desk team should be collecting this prior to the visit. Also, if the patient account has a balance related to deductible or co-insurance that has not been paid, the front desk should be collecting these at the appointment. Practices that adhere to a consistent policy of collecting at the front desk achieve the highest collection rate.

Clear Communication: Setting expectations with parents around financial policies, balances, and forms. The front desk team should be communicating the practice financial policies that include payment of copays, deductibles and co-insurance during the check in process. Practices that have front desk team members that consistently communicate and collect at the front desk achieve the highest level of collection.
Impact: Mistakes or omissions at this stage can lead to delays, denied claims, and patient dissatisfaction. A well-trained front desk team is a revenue cycle superpower.
2. Provider: Selection of coding based on the clinical visit.
While their main focus is delivering excellent care, providers play a critical RCM role through documentation and coding. Key responsibilities include:
Accurate Clinical Documentation: Thorough notes that support the billed services. The clinical notes should support the CPT codes and ICD10 diagnosis codes selected for the visit. If a claim is rejected due to a combination of CPT codes and ICD10 codes, a billing team member considers that clinical documentation to make ICD10 updates. Areas that additional documentation might be needed include adding a sick visit code to a well visit as well as selection of a higher sick visit code (e.g. 99214 and 99215).

Appropriate CPT and ICD-10 Coding: Capturing the complexity and necessity of the visit. There are two approaches for selection of a sick visit CPT code, either time or complexity. If the visit is complex such as an ADHD initial diagnosis, the provider should select a higher level code to match the complexity (e.g. 99214 or 99215) of the visit. Parameters such as diagnosis complexity and if a medication was dispensed are factors in determining visit complexity. Previous newsletters provide further details on selecting appropriate E&M codes based on visit complexity or time.

Timely Chart Completion: Ensures that claims are not delayed due to outstanding documentation. While it is ideal for clinical charts to be complete within the same day as the visit, there are times that the provider might need extra time to complete the chart. A provider should have over 90% of their charts completed within seven days of the visit. Timely completion of the charts supports optimal revenue cycle management as well as clinical patient management. The owner and/or leader of Pediatric practice should monitor chart completion weekly and manage any issues with select providers that are not completing their charts within seven days of the clinical visit.
Communication with Billing Team: Clarifying unusual cases, denials, or payer questions when sent by a billing team member. Sometimes there are claim rejections that a billing team member needs a clarification from the provider that completed the visit. This occurs if the clinical note either is missing or has incomplete documentation for the medical billing to resubmit a claim rejection.
Impact: Even the best biller can’t submit a clean claim without clear, complete, and timely documentation from the provider.
3. Biller: The Revenue Navigator
Billers are the financial backbone of the revenue cycle. They translate the services provided into reimbursable claims and ensure every dollar is pursued. Responsibilities include:
Claim Submission: Accurate, timely, and compliant with each payer’s guidelines. While there is a standard approach to Pediatric Coding established by the American Academy of Pediatrics, some payers have additional requests related to optimal reimbursement for certain clinical visits such as well visits. This information should be posted by the payer and transparent to the practices and medical billing team. These variations and/or customizations of billing rules by some payers take time and resources for the medical billing team to consistently manage.

Denial Management: Identifying trends, correcting errors, and resubmitting claims. Denials can occur due to a number of reasons including ICD10 diagnosis coding edits that payers implement that reject either the entire claim or specific CPT codes. While the provider might select a very specific ICD10 diagnosis, at times the payer rejects diagnoses that they view are not appropriate. These edits are dynamic and change over time. Being specific to Pediatrics, we are able to identify these trends and take corrective action to obtain optimal reimbursement for Pediatric practices.

Accounts Receivable Follow-Up: Chasing down unpaid claims and outstanding balances. Claims can be unpaid for a variety of reasons. If the front desk team does accept an invalid insurance, the billing team will send a patient statement identifying that the patient has no insurance and flag the account for the front desk to collect as well.

Patient Billing Support: Sending statements, setting up payment plans, and answering parent questions. The billing team also sends out patient statements to collect the patient responsibility. If this is not collected on the first statement, additional statements are sent to the family.

Impact: A proactive billing team ensures that your practice gets paid efficiently and that revenue doesn’t leak through the cracks.
Teamwork Makes the Revenue Work
RCM is not a siloed process—it’s a relay race. If one team member fumbles, the entire process can suffer. Optimal performance of the front desk team and pediatric providers while working with the Physician Xpress billing team can:
Improve cash flow and reduce days in A/R

Lower denial rates

Boost patient satisfaction with transparent billing

Reduce staff burnout from repetitive errors and rework