- Road To Carry Newsletter
- Posts
- 🗓 Weekly Rollup: DOGE & Revenue Cycle Management
🗓 Weekly Rollup: DOGE & Revenue Cycle Management
DOGE probe into Medicare and Medicaid
What’s Topical
Source: CMS
Last week, The Wall Street Journal reported that representatives from Elon Musk’s Department of Government Efficiency (DOGE) have gained access to the payment and contracting systems at the Centers for Medicare and Medicaid Services (CMS). Their primary objective is to evaluate CMS’s technology infrastructure and identify inefficiencies—with a key focus on reducing Medicare and Medicaid fraud, which the Department of Health and Human Services (HHS) estimated at over $86 billion in 2024.
DOGE’s investigation into Medicare and Medicaid payments could have significant implications for private equity, particularly in the outsourced revenue cycle management (RCM) industry—a sector that has seen substantial PE investment in recent years. Notable recent deals in the RCM space include:
- New Mountain’s acquisition of Access Healthcare for ~$2 billion (January 2025)
- TowerBrook and CD&R’s joint acquisition of R1 RCM for $8.9 billion (November 2024)
- EQT’s acquisition of GeBBS Healthcare Solutions for ~$850 million (September 2024)
What is Revenue Cycle Management?
Revenue Cycle Management (RCM) refers to the process by which healthcare providers (e.g., hospitals, clinics) capture, process, and optimize patient billing data to maximize collections—primarily from insurance companies, Medicare, and Medicaid—while minimizing delays in payment.
Because the process involves multiple complex and often manual steps, many healthcare providers outsource RCM operations to third-party specialists to improve efficiency and accuracy. The key steps in the RCM process are outlined below:
Source: Jorie AI
Patient Registration & Scheduling – Collecting accurate patient information and setting up appointments.
Insurance Verification & Authorization – Confirming insurance coverage and securing approvals for procedures.
Charge Capture – Assigning correct medical procedure and diagnosis codes to ensure accurate billing.
Billing & Claims Submission – Preparing and submitting clean claims to insurers, Medicare, and Medicaid while generating patient invoices.
Payment Processing – Managing reimbursements from payers and collecting patient payments.
Denial Management – Reviewing and addressing denied claims to prevent future issues.
Accounts Receivable Follow-up – Tracking and following up on unpaid charges to ensure timely collections.
Reply