For large provider networks, public health authorities, and third-party billing companies, the revenue cycle remains one of healthcare’s most persistent challenges. Claims bounce between systems, payments are delayed, and no one has a clear view of what’s been approved or why it was denied. The result? Lost revenue, cash flow issues, and frustrated staff and patients.
RCM (revenue cycle management) is a strategic priority. And yet, much of it still runs on outdated tools and disconnected processes. According to recent research, medical coding and billing mistakes cost hospitals between 1% and 5% of net patient income each year. For a typical 250-bed hospital, this translates to $5-11 million in lost annual income.
This is why more healthcare leaders are moving toward a platform-based approach to RCM. Instead of relying on disconnected systems, they’re investing in unified platforms that bring together payers, providers, and billing partners under one set of standards, shared logic, and real-time workflows. The goal isn’t just automation, it’s transparency and scalability across the ecosystem.
According to Bain & Company’s latest Global Healthcare Private Equity Report, RCM is the top investment priority for healthcare executives in 2025, even ahead of clinical software. Among 200 surveyed leaders, most plan to increase spending on tools like charge capture, complex claims management, and revenue integrity.
“Providers cite RCM as a top priority, anticipating higher spending for software across a broad set of subsegments.”
— Bain & Co., 2024
At Edenlab, we help healthcare systems achieve this by building interoperable RCM platforms, designed to facilitate relationships between multiple stakeholders and fit complex environments, connect seamlessly with existing tools, and meet the demands of scale, compliance, and performance.
In this article, we unpack what RCM as a platform really means, how it works in practice, and why it’s becoming a cornerstone of modern healthcare operations.
Highlights:
- Medical coding and billing mistakes cost hospitals between 1% and 5% of net patient income each year, or $5–11 million annually for a typical 250-bed hospital.
- Among 200 healthcare leaders surveyed by Bain & Company, revenue cycle management technology topped the list of software investment priorities in 2024, ahead of even clinical systems.
- A platform-based RCM system helps reduce manual rework, delays, and denials by unifying providers, payers, and billing companies in a single shared environment.
- Traditional automated medical billing systems rely on EDI and disconnected portals, while modern platforms use FHIR-based APIs and real-time data exchange.
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Check our medical billing and claim software development services.What Is RCM-as-a-Platform and Why It Matters Now
Many healthcare organizations still manage billing through a patchwork of disconnected systems. A provider submits a claim in one tool, the payer reviews it in another, and a third party might step in to handle exceptions, often by hand. The more players involved, the harder it gets to keep things moving, especially when each partner uses different rules and formats.
A revenue cycle management platform offers a different approach. Instead of stitching together one-off connections, it acts as a shared layer between all sides of the claim and billing process. Providers, payers, and intermediaries keep their internal systems but connect through common APIs, shared rules, and real-time data exchange. This turns disjointed workflows into one coordinated process.
There are two common ways these platforms are set up:
- Facilitator-driven ecosystems. A government body, integration vendor, or third-party billing provider runs a centralized platform that brings together multiple payers and providers. Everyone connects to the same system, making coordination and automation much easier.
- Provider-owned platforms. A large hospital group or network builds a platform to manage its payer contracts, billing workflows, and internal branches under one roof, with full control.
Who operates the RCM platform matters because it determines the level of control a provider has, how integrations are managed, and how smoothly the system operates across parties.
When healthcare providers own the platform, they gain flexibility but also carry the full burden of connecting to each payer. A third-party billing company takes on that complexity, offering a shared infrastructure with built-in payer connections, albeit with less room for customization. In public or national systems, the platform may be owned by a health authority, enforcing consistency, but often at the cost of speed and adaptability. The right model depends on scale, internal capacity, and the level of ownership a provider wants over real-time billing workflows. For payers, platforms that follow shared standards (like FHIR-based APIs) make it easier to connect, regardless of who’s on the other side.
Legacy RCM Processes vs. Platform-Based RCM
A revenue cycle as a platform isn’t just a technical shift. It’s a shift in how the business of care operates. Claims move faster. Rules are clearer. Fewer things go through the cracks, and when they do, they’re easier to catch. The result is cheaper expenses, faster reimbursements, and a better experience for everyone involved.
Here’s how that shift looks in practice:
| Traditional RCM workflow | Platform-Based RCM workflow | |
| System Setup | Siloed tools, custom logic for each payer or provider | Shared platform with modular components built for collaboration |
| Data Exchange | Point-to-point APIs and EDI files, often limited in scope and repeated for each data need | FHIR APIs are designed to return complete, structured patient and billing data in a single, reusable interaction |
| Transparency | Each stakeholder sees only part of the process | All parties share the same data and traceable workflow steps |
| Workflow Efficiency | Manual routing, rework, and fragmented steps | Automated, structured processes across the full billing lifecycle |
| Integration | Point-to-point connections with high maintenance overhead | Seamless integration with EHRs, payers, and third parties through unified APIs |
| Security & Compliance | Added on after implementation, limited traceability | Built-in controls: audit logs, access rules, and consent-aware data sharing |
| Scalability | Hard to expand across networks or partners | Multi-tenant, multi-organization support |
| Maintenance | High cost of updates and duplicated effort across tools | Centralized logic and modular updates make evolution easier |
| Business Impact | Slower payments, higher denial rates, and rising admin costs | Faster revenue cycles, fewer errors, and stronger financial performance |
Core Capabilities of a Platform-Based RCM System
Unlike traditional RCM tools, which are often built around a single organization’s needs, a healthcare revenue platform supports shared business processes across an entire network. It connects providers, payers, and billing partners through a common logic, even when they use different systems internally. Instead of each party working in isolation and exchanging files, they collaborate in real time, across unified workflows that match how revenue is actually generated and reconciled in healthcare.
At Edenlab, we build RCM as a shared platform, where these actors interact through modular components and APIs — all connected by a common business logic. Below is a typical architecture we develop for clients managing complex, multi-entity claim and billing environments.
What It Looks Like in Practice
At its core, RCM as a platform needs to serve everyone involved without disrupting how each organization works. To support that, Edenlab structures its solutions across key stages and layers:
1. Healthcare Billing Workflow Processes
A strong digital Revenue Cycle Management (RCM) platform mirrors how care is transformed into payment, step by step, with clear accountability among all stakeholders. Every interaction is digitized, traceable, and prepared for automation, ensuring transparency and efficiency throughout the process.
At its core, an RCM platform manages and routes requests between billing stakeholders, reducing manual effort and minimizing errors. Let’s walk through the main types of transactions that such a platform automates.
Eligibility and Coverage Check
Before a patient’s visit, the provider — whether a hospital, primary care clinic, or laboratory — needs to confirm coverage with the payer. The payer can be a healthcare insurance company (HIC) or a third-party administrator (TPA). The goal is to verify in real time that the patient is entitled to receive the requested services.
In a modern RCM setup, this check is performed through standardized APIs, allowing eligibility confirmation to occur instantly. This reduces administrative burden on back-office teams and speeds up patient intake.
Prior Authorization
For certain procedures or medications, prior authorization from the payer is required. The RCM platform can detect when an authorization is needed and automatically submit the request using structured clinical data. Responses are returned digitally, providing not only approval or denial but also the reasoning behind the decision.
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Automating Prior Authorization with FHIRCoding and Claim Preparation
Once care has been delivered, providers must accurately code the services according to standardized medical coding systems. This ensures interoperability and consistent exchange of healthcare information across systems. The RCM platform supports providers by streamlining coding, flagging errors, and preparing claims for submission.
Claim Submission and Adjudication
Finally, claims are submitted electronically from the provider to the payer. The platform automatically matches claims against coverage rules, with responses returned digitally. These responses may confirm approval, indicate partial payment, or request revisions. By automating adjudication workflows, the platform reduces delays and ensures faster reimbursement.
For one of the largest TPAs in Hong Kong, Edenlab developed a FHIR-based auto-adjudication engine that automates complex claims and pre-auth workflows. The project began by structuring fragmented insurance plans and mapping disparate data to FHIR resources, such as Claim, Coverage, and ClaimResponse. We then created a domain-specific model and integrated APIs and user interfaces for eligibility checks, plan management, and real-time adjudication. The end product is a fully functional rule engine that supports deductibles, copays, coinsurance, age limitations, and other features, enabling customers to reduce manual processes, increase efficiency, and confidently expand their operations.
Payment and Reconciliation
Actor: Payer → Provider
Once payment is made, the remittance advice is matched to the original claim. The platform flags any discrepancies, posts the transaction, and closes out the receivable.
For instance, we built a national-scale message exchange hub that streamlines financial interactions between providers and payers across an entire healthcare system. Using the FHIR Messaging approach, the platform enables real-time data exchange for every key step in the revenue cycle, from eligibility checks and prior authorization to claims, payment reconciliation, and notifications. It is built on common FHIR resources such as CoverageEligibilityRequest, Claim, PaymentReconciliation, and Communication, and is intended to function across several enterprises. Instead of relying on fragmented point-to-point connections, this hub establishes a unified architecture that streamlines compliance, enhances coordination, and enables scalability from the outset.
2. Real-Time Reporting and Analytics
Modern RCM platforms don’t just track transactions; they surface insights. With built-in dashboards and predictive analytics, teams can track rejection patterns, anticipate revenue, and identify problems before they impact cash flow.
3. Integration Layer
No revenue cycle solution works in isolation. To actually move claims, check coverage, or get paid, it has to talk to two kinds of systems: the provider’s internal tools (like the EHR) and the outside world of payers, clearinghouses, and networks.
That’s where FHIR-based billing integration comes in. Every payer has its own setup: different APIs, formats, rules, and security requirements. A modern RCM platform needs to connect with all of them. That might mean real-time APIs with one payer, file-based X12 exchanges with another, or FHIR-based workflows for prior auth. These connections don’t come pre-built; they have to be constructed, tested, and maintained.
The same goes for provider-side systems. When the billing system doesn’t connect with the EHR, teams often have to copy data by hand or move between tools just to keep a claim going. It slows things down and leads to errors. A properly connected platform pulls what it needs from the EHR and pushes updates back in — no double entry, no guessing, no hold-ups.
4. Interoperability and Data Exchange
Interoperable RCM solutions are only as strong as their ability to connect all stakeholders (providers, payers, and third-party billing companies) without friction. That’s why interoperability isn’t optional. Modern platforms rely on established standards, such as HL7v2 and X12, but FHIR integration for billing is what enables the real-time, flexible exchange.
FHIR isn’t just a newer standard; it’s designed for the way modern systems communicate. It enables fast, API-based data sharing that works across different tools and setups. That means cleaner integrations, quicker turnaround on claims and prior authorizations, and far less manual work.
The platform handles all core transactions, from eligibility checks and prior auth to claims and remits using both standard EDI formats (270/271, 278, 837) and modern FHIR-based workflows like PAS. It also supports clinical codes such as ICD-10, SNOMED CT, CPT, and LOINC. However, the real value lies in making these exchanges routine, rather than a project. FHIR allows data to flow safely between systems, even if one side uses a conventional EMR and the other a cloud-based EHR. This is how you go from fragmented billing systems to a scalable, responsive, and flexible solution.
5. Security and Compliance
In revenue cycle management, trust is everything. You’re dealing with protected health information (PHI), financial transactions, and access rights that span multiple organizations. And with CMS, HIPAA, GDPR, and other regulatory frameworks tightening their requirements, compliance can’t be bolted on; it must be built in.
That’s why security and access control aren’t just infrastructure concerns in a modern RCM platform; they’re architectural principles. When done correctly, they not only protect data but also facilitate smoother collaboration among payers, providers, and external vendors.
Edenlab takes a compliance-by-design approach across every layer of the platform:
- Secure APIs with scoped access
All endpoints are protected by OAuth 2.0 and OpenID Connect. We use access tokens with clear scopes tied to user roles, organizations, and specific permissions. This ensures that each actor (whether a provider user, healthcare billing platform, or payer API) can access what they’re supposed to.
- Role-based and attribute-based access control (RBAC & ABAC)
We implement flexible models where access is defined not only by role (claims processing reviewer vs. billing coordinator) but also by attributes like facility, time, or consent. This is essential in multi-tenant, cross-organizational platforms.
- End-to-end audit trails
Every activity, from claim revisions to prior authorization approvals, is documented and time-stamped. These logs are linked to user identities and data items, providing complete traceability — a crucial feature for HIPAA audits or payer-provider disputes.
- PHI protection
We employ TLS 1.2+ for all transport-level security and AES-256 encryption for storage. Depending on the data use case (for example, analytics vs. transactional processing), all PHI is encrypted, pseudonymized, or completely anonymized.
- Consent-aware data sharing
Our platforms include built-in mechanisms to enforce patient consent across systems and jurisdictions, especially important in HIE scenarios where multiple organizations interact with a single patient record.
Edenlab created Ukraine’s national e-prescribing system, which digitizes and secures government medicine reimbursement schemes. The technology enables real-time validation, patient verification, and fraud-resistant workflows by converting paper-based operations into traceable digital interactions. With over 75 million prescriptions handled and more than 15,000 pharmacies on board, it provides trustworthy data to the government for prompt payments, analytics, and large-scale health policy planning.
6. Multi-Entity Flexibility
Finally, these platforms are made for the real world, where one third-party billing company might serve 300 providers, or a hospital group might work with 50 different payers. We support multi-tenant, multi-organization setups with scoped access, custom workflows, and adaptable interfaces within the same architecture.
The U.S. RCM Landscape: Why It’s Especially Complex
The U.S. healthcare system is notoriously fragmented, and that complexity extends beyond clinical care. The revenue cycle is where fragmentation becomes operationally painful. Providers often work with dozens of payers, each with their own systems, approval rules, and claims logic. Third-party billing companies are expected to coordinate benefits and payments across entire networks. And payers need to enforce policy rules at scale without alienating provider partners or delaying care.
This environment demands far more than a basic billing tool. It requires the revenue cycle applications to be built to connect multiple organizations across various workflows, while maintaining regulatory compliance and adapting to rapidly changing CMS requirements.
At Edenlab, we help teams navigate:
- Regulatory issues: The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) now mandates the use of specific FHIR-based APIs, including support for real-time eligibility, coverage, and prior authorization interactions. We implement those workflows using Da Vinci CRD, DTR, and PAS guides.
- Claim complexity: U.S. RCM systems must support both institutional and professional claim types, layered benefit plans, and reconciliation with remittance advice and patient responsibility components.
- State-by-state variability: Regulations and payer participation vary widely, so billing workflows must be flexible, modular, and easily configurable without compromising compliance.
We’ve seen what happens when these workflows are held together by brittle logic, outdated standards, or manual steps. It slows reimbursement, increases denials, and drains resources. That’s why we build RCM platforms designed for the U.S. market: modular, compliant, and built for real-world scale.
Conclusion
As healthcare becomes more complex, fragmented, and data-driven, the traditional approach to managing the revenue cycle, with siloed tools, manual processes, and rigid integrations, is no longer sufficient. RCM as a platform offers a smarter, more sustainable alternative: one that connects providers, payers, third-party billing companies, and product teams in a shared environment designed for scale, speed, and interoperability.
At Edenlab, we believe RCM should work like the rest of modern healthcare IT: API-first, standards-based, and deeply integrated into the systems people already use. Whether you’re building from scratch or modernizing existing infrastructure, a platform approach enables you to streamline financial workflows, meet evolving regulations, and respond to real-world complexity without having to start over each time the market shifts.
This is a strategic move toward faster reimbursements, stronger partnerships, and more resilient systems. And it’s already happening across national networks, growing startups, and everything in between.
If you’re ready to rethink how revenue works in healthcare, we’re here to help you design the platform to support it.
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From national HIEs to FHIR-native claims engines, we design systems that connect payers, providers, and TPAs around shared, scalable workflows. If you're building something complex — or need to — we’re here to help make it real.
FAQs
What’s the difference between RCM software and RCM as a platform?
Revenue cycle management software typically addresses only one aspect of the problem: it may help a provider submit claims or track payments, but it’s often disconnected from the broader context. In turn, RCM as a platform connects everyone involved in the revenue cycle through a single, flexible system. It’s built for collaboration, automation, and scale, not just task management.
How can modular RCM platforms support payers and providers at once?
A modular revenue cycle software provides payers and providers with access to the same ecosystem, but through workflows designed specifically for each group. Providers can submit claims and track statuses. Payers can review, adjudicate, and respond using shared, real-time data. This reduces delays, minimizes miscommunication, and makes collaboration far more efficient.
Can I build custom apps on top of an existing RCM platform?
Yes, it is precisely what current RCM platforms are designed for. With open API-driven RCM systems, you can create custom apps tailored to your specific needs, including dashboards, patient billing tools, and analytics, without disrupting key operations. It allows you to innovate without having to reinvent the wheel.
How do open APIs in healthcare affect long-term vendor lock-in?
Open APIs provide flexibility. They make it easy to add new tools, change individual components, and scale without being reliant on a single vendor. Your data is portable, your workflows remain yours, and your firm can adjust without starting over.
What are the first steps to move from legacy billing to an API-first RCM model?
Start by finding the biggest pain points — maybe it’s slow claims processing or disconnected billing systems. Then, look for a platform that supports modern standards, such as FHIR, and allows for phased adoption. You don’t need a full rebuild. Start with one area that creates immediate value and expand from there with minimal disruption.
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