Whether you work for a full-scale enterprise or a smaller healthcare facility, revenue integrity programs’ increasing importance is consistent; beyond ensuring accurate billing and collection, these programs should strengthen reimbursement performance and provide sound financial practices.

Revenue cycle management (RCM) is a well-established concept in the business of healthcare, traditionally affiliated with the application of best practices regarding claim submission, coding and billing, operations, and patient access. As the blueprint for a reimbursement strategy, a sound RCM program ultimately drives financial performance.

However, even a well-structured RCM program can possess gaps that result in missed revenue, compliance risks, and failure to resolve issues. There is a certain level of acceptance of this missed revenue. However, with growing complexities regarding reimbursement, providers today simply cannot afford the luxury of leaving money on the table ─ hence, the birth of revenue integrity (RI).

There has been a continual rise in revenue integrity’s importance and the need to connect all the clinical and operational links in the chain in recent years. Revenue integrity, as a division of RCM, involves processes that ensure workflows for revenue accuracy. RCM establishes procedures, and revenue integrity is considered the building block to ensure accuracy, consistency, and optimal reimbursement.  Essentially, revenue integrity is a critical link that should by design connect clinical operations with coding and business office functions.

This remains a developing function for hospitals and health systems, however, with the ever-volatile environment of healthcare revenue integrity becoming a top priority of financial leaders in healthcare.

Is it time to re-assess your RI functions?

Understandably, revenue integrity as an enterprise function is an evolving process. RI may be an established division within a healthcare facility, or it could operate under the umbrella of RCM. This includes encompassing broader areas to consistently drive reimbursement performance, such as keeping up with an organization’s growth, advancements in technology, and electronic health records – as well as the emerging value-based payment models.

Establishing distinct revenue integrity functions creates another way to combat decelerated revenue, distinguishing precisely where a claim may not pass billing edits or wind up being denied, and pinpointing solutions for denials and extended delays.

There are several key questions every provider should ask of themselves:

Where are your edits and denials?

It’s fair to say that many edits and denials are lost in the shuffle, never to be seen or heard from again. For example, if an edit is discovered and returned to the initial department, if there is not a designated individual responsible for its resolution, it may be held indefinitely. As you track issues back to the department source, often, duplicates are discovered.

Who is working on your edits?

A designated, knowledgeable staff is the key to success. Develop a team with the right skill set to work edits. This skill set should include knowledge of all aspects of revenue cycle functions, Centers for Medicare & Medicaid Services (CMS) regulations, federal and state regulations, medical records, and terminology. Individuals with the ability to quickly and accurately assess data and interpret qualitative, quantitative, and financial analysis are essential.

Your revenue integrity lead or manager must own all facets of what’s involved in successfully connecting links across charge services and clinical departments. Ideally, the head of RI will be most successful if they report to revenue cycle, rather than the billing department.

Who is educating departments in response to repetitive issues?

Providing ongoing education is a crucial component to effective revenue integrity. All stakeholders and department heads should receive consistent education in targeted areas to ensure claim accuracy. Coding and compliance training and education are essential, along with the ability to add modifiers and correct erroneous charges ─ so always provide online resources and the most updated material.

To ensure high-level productivity and quality, establishing a strategic monitoring system will help track trends and gather the critical data required to understand the bigger financial picture and find gaps in the revenue cycle.

The cross-functional dynamics of RI functions provide oversight that exposes valuable detail in identifying and resolving revenue issues. To ensure an effective system, there must be comprehensive monitoring and tracking in certain key areas, such as:

  • Edits: Track the number of accounts being stopped by edits to distinguish patterns causing delays in claims processing and payment. Identify payor requirements and the source of issues to implement automated resolutions, and prevent repetitive edits through targeted education.
  • Denials: Track trending claim denial patterns (medical necessity, level of care, and provider). Identify issues with revenue code and CPT code/HCPCS combinations to address workflows that cause submission errors. This includes monitoring not only dollar amounts but also denial percentages ─ compare your figures to industry standards to set performance goals.
  • Pre-bill/post-bill claim edits: Identity claims relevant to any clinical or coding review or required modifier, based on services rendered.
  • Write-offs: Every facility has a ceiling to the acceptable amount of write-offs expected. It is vital to examine write-offs against revenue to your facility’s cap percentage of net patient revenue is in line.
  • Underpayments: A critical function of RI is monitoring underpayment levels and tracking efforts to resolve associated issues; this will recover more dollars.

These identifiers are simply a sample of what is required of RI to successfully expose revenue leaks and compliance risks. Though a small sampling, this certainly illustrates the importance of revenue integrity to the revenue cycle.

It is more than just ensuring that hospitals are billing and collecting payment correctly; revenue integrity at its core is a focus on the patient and making sure the medical record is being accurately reflected in all transactions, diagnoses, and treatments.

Your RI process can be simple or complex, depending upon your organization’s size and current structure. Having structured revenue integrity functions will proactively provide a layer of protection against compliance risk and missed revenue.

Creating an effective revenue integrity program can be challenging, but the rewards in enhanced revenue and reduced compliance risks are worth the effort. If establishing or enhancing your revenue integrity seems costly, consider the fact that an effective revenue integrity department can drive up to $20 million in unclaimed revenue. The investment more than pays for itself!

In today’s complex, competitive healthcare environment, there is no question that focusing on a revenue integrity department is in the best interests of any organization.

Programming Note: Listen to Susan Gatehouse report this story live today during Talk Ten Tuesdays, 10 a.m. Eastern.

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