Administrative Workflows in Healthcare
Overview
Behind every patient encounter are administrative processes that enable access, payment, and compliance. Prior authorization, referrals, scheduling, billing, coding, and record management form the backbone of how care is approved, tracked, and reimbursed. When these workflows are efficient and well integrated, care teams spend less time on paperwork and more time on patients.
Vim reduces administrative friction by connecting payer requirements and provider workflows in one place. The terms in this section define the key administrative concepts that affect access to care, revenue cycle, and day-to-day operations in healthcare.
Related Concepts
Billing
Definition:
Billing is the administrative process of submitting claims to payers and invoices to patients for healthcare services rendered. It includes charge capture, claim submission, adjudication follow-up, denial management, and financial reconciliation within the revenue cycle.
Why it matters:
Accurate billing ensures appropriate reimbursement, reduces claim denials, and supports financial sustainability for provider organizations. Billing performance depends on precise documentation, correct coding, and alignment with payer requirements.
Chart Chasing
Definition:
Chart chasing refers to the manual effort required to locate missing documentation, lab results, or historical medical records needed for care delivery, quality reporting, audit response, or reimbursement validation. It often involves phone calls, fax requests, portal logins, and coordination between multiple organizations.
Why it matters:
Chart chasing increases administrative burden, delays clinical workflows, and consumes staff resources that could otherwise support patient care. Reducing manual documentation retrieval improves operational efficiency and accelerates performance reporting and reimbursement processes.
Coding
Definition:
Coding is the assignment of standardized diagnosis and procedure codes to clinical services and documented patient encounters. Common coding systems include ICD-10 for diagnoses and CPT for procedures and services used in billing and reporting.
Why it matters:
Coding accuracy directly affects reimbursement, risk adjustment scores, quality reporting, and audit compliance. Incomplete or incorrect coding can lead to payment discrepancies, performance measurement gaps, and regulatory risk.
Health Information Management
Definition:
Health information management (HIM) is the discipline focused on maintaining the accuracy, integrity, privacy, security, and accessibility of patient health information across healthcare systems. HIM teams oversee documentation standards, record release processes, data governance, and regulatory compliance.
Why it matters:
Effective health information management supports audit readiness, reduces compliance risk, and ensures accurate data exchange between providers, payers, and other stakeholders. Strong HIM practices are foundational to quality reporting, risk adjustment accuracy, and secure interoperability.
Medical Record Retrieval
Definition:
Medical record retrieval is the process of obtaining patient health information from internal systems or external organizations. This may involve requesting encounter notes, laboratory results, imaging reports, or historical documentation to support clinical decision-making, billing, audits, or quality reporting.
Why it matters:
Timely access to complete and accurate patient records improves clinical decision-making, supports coding accuracy, and strengthens compliance with regulatory and quality requirements. Delays in record retrieval can interrupt workflows and affect reimbursement validation and performance measurement.
Outreach
Definition:
Outreach refers to proactive communication with patients to encourage specific actions, such as scheduling preventive services, completing recommended screenings, attending follow-up visits, or adhering to treatment plans. Outreach may be conducted through phone calls, patient portals, text messaging, or automated communication systems.
Why it matters:
Effective outreach helps close care gaps, improve quality measure performance, and support population health management strategies. Structured outreach programs increase patient engagement, reduce avoidable utilization, and contribute to stronger performance under value-based contracts.
Prior Authorization
Definition:
Prior authorization is a utilization management requirement in which a payer must approve a specific service, medication, procedure, or diagnostic test before it is reimbursed. The process typically involves submission of clinical documentation, verification of coverage criteria, and confirmation of medical necessity under the patient’s health plan.
Why it matters:
Prior authorization directly affects access to care, treatment timelines, and administrative workload. Delays or inefficiencies in authorization workflows can postpone necessary treatment, increase staff burden, and create operational friction between payers and providers. Streamlined authorization processes improve patient experience and reduce avoidable administrative overhead.
Referral Management
Definition:
Referral management is the operational process of initiating, tracking, coordinating, and completing patient referrals between primary care providers, specialists, facilities, and community resources. It includes verifying coverage requirements, obtaining prior authorizations when necessary, coordinating scheduling, and confirming visit completion and documentation.
Why it matters:
Effective referral management ensures patients receive timely specialty care, reduces leakage outside contracted networks, and supports coordinated care delivery. In value-based care environments, strong referral workflows contribute to quality performance, cost control, and improved patient outcomes.
Referrals
Definition:
A referral is a formal request for a patient to receive evaluation, consultation, or treatment from another clinician, specialist, facility, or care setting. Referrals are commonly initiated in primary care and may be required under certain health plan structures to ensure coverage eligibility.
Why it matters:
Proper referral execution improves access to appropriate expertise, strengthens continuity of care, and supports performance metrics tied to cost and quality outcomes. Clear referral documentation and follow-through are essential for coordinated care and accurate reporting.
Scheduling
Definition:
Scheduling is the administrative process of arranging patient appointments, follow-up visits, diagnostic services, and specialty consultations across providers and care locations. It often includes eligibility verification, appointment reminders, and coordination across multiple departments.
Why it matters:
Efficient scheduling improves patient access to care, reduces no-show rates, and supports capacity planning within provider organizations. Optimized scheduling workflows help ensure that referrals are completed, preventive services are delivered on time, and operational resources are used effectively.