According to a recent survey conducted by the Healthcare Financial Management Association (HFMA), “Ten years ago, few hospital administrators would have listed revenue integrity as a top organizational priority, but it is now more important than ever.” Revenue integrity is the top priority for nearly a quarter of hospital CFOs.
However, before implementing new practices and guidelines to address revenue integrity, it is necessary to define what revenue integrity means. And how does it fit into your organization’s current strategy, as well as how will it be implemented?
What is Revenue Integrity?
To avoid compliance risk and revenue loss, hospitals are increasingly establishing revenue integrity careers and departments. According to the National Association of Healthcare Revenue Integrity (NAHRI), the goal of RI is “to prevent the recurrence of issues that can cause revenue leakage and/or compliance risks across the continuum of patient care, supported by appropriate documentation and the application of sound financial practices that can withstand audits at any point in time.”
Revenue integrity in healthcare
Revenue integrity appears to be a constant buzzword in every industry. However, in healthcare, it is more than just a buzzword; it is a way of doing business that separates organizations that grow and thrive from those that merely survive. Almost every hospital CFO recognizes the importance of revenue integrity, but many are still experimenting with how RI fits into their organization.
In the healthcare industry, for example, we are concerned with revenue integrity to make an honest buck. A hospital that has institutionalized revenue integrity has most likely established a set of policies and procedures that require all associates, particularly those involved in the revenue cycle, to do the right thing. That means coding encounters in a way that maximizes legitimate reimbursement in the mid-revenue cycle. The word to remember here is “legitimate,” as in legally and contractually compliant.
A hospital’s revenue integrity entails more than just being morally upright. Being fully compliant in coding and billing practices lowers the risk of costly downstream efforts such as managing external audits and even payment denials. Revenue integrity leads to operational efficiencies.
RI is viewed as an evolution of current efforts to reduce compliance risk and increase revenue by many hospitals. It usually entails making improvements in three areas:
Many systems separate clinical operations from coding and revenue cycle from coding. While honoring existing, functional workflows, RI creates new workflows to reduce compliance risk and increase reimbursement.
Without RI, employees work in their specialty and are trained in one of three different functions: clinical, coding, or revenue cycle. With RI, teams of people lend specialized understanding to efforts to collaborate and ensure that efforts are aligned toward the appropriate goals.
Just recently have specific technologies have been developed to bridge data gaps and facilitate more coherent workflows between clinical, coding, and revenue cycle departments. RI platforms connect disparate data sources, and artificial intelligence (AI) and machine learning are increasingly being used to optimize RI efforts.
How do stakeholders view revenue integrity?
Doctors play an important role in the revenue cycle because the billing process starts with their initial documentation. Physicians have a role to play in optimizing patient engagement by accurately documenting care and quality measures, and interfacing with the HIM/coding department, when necessary.
The responsibility of allocating resources throughout the organization often rests on the shoulders of the CFO. He or she should be able to develop an accurate representation of what level of revenue integrity is being achieved, what opportunities exist in terms of addressing it, and the respective impact of each.
- Quality officer
Patients are at the center of the revenue cycle. When it comes to revenue integrity, the quality officer needs to ensure that the patient experience— including outcome quality, acuity of care, and the requested reimbursement— is accurately reflected in the final bill.
- Compliance officer
True revenue integrity depends on strict adherence to all laws and regulations. These can change frequently, so what worked yesterday may no longer be effective today. The compliance officer should develop reports that show how new regulatory developments impact the organization’s processes and overall revenue cycle and work with each stakeholder to adjust accordingly.
- Coding director
The coding department is also focused on compliance, though from another angle. It’s up to the coding director to support the coding staff as well as any clinical documentation improvement programs in a manner that aligns with revenue integrity goals.
Keeping everyone pointed in the same direction requires greater transparency and communication between departments and acute attention to detail. It starts with a plan, but without the right technology, executing that plan can be an insurmountable task.
Implement revenue integrity using technology
Conducting internal coding audits to improve accuracy just before bill drop can cause delays and be very costly. Post-billing audits are similarly restricted because they typically focus on small, random samples of cases. This retrospective feedback occurs after denials or compliance issues have occurred, indicating that root causes are unchecked and efforts are limited to reacting to, rather than preventing, the accuracy and efficiency issues that hinder revenue integrity.
The solution here is to focus the intelligence of skilled auditors on a machine. Expert rules and pattern recognition on historical auditor data (also known as machine learning) can be a game-changer for a revenue integrity program. All coding can be analyzed before billing using automated scanning. Cases with questionable code combinations are flagged for review, while those with acceptable accuracy can proceed to the bill. It’s a more manageable way of screening all encounters while allowing for the most efficient use of resources on the highest priority cases.
Automation has the potential to be the key to achieving revenue integrity in many ways. As government regulations and payment methodologies become more complex, hospital administrators, coding staff, and others struggle to keep up. Every underperforming element of the revenue cycle adds up in terms of lost revenue, increased risk of RAC audits, and underreported quality measures. For example, if it takes several days after a patient’s discharge to generate a bill, and then weeks or even months to audit that bill, any errors within it are virtually irreversible. Even if it contains errors that cost the organization thousands of dollars, there is often little that can be done about it. The revenue cycle does not take breaks, and as a result, revenue integrity and overall financial performance suffer.
Every stakeholder in the revenue cycle is empowered to do their job and support revenue integrity with integrated technology and automated solutions. RCM solutions can free up resources, allowing administrative staff to complete their tasks more quickly. Don’t take shortcuts to revenue integrity. Start now if you’re one of the more than half of healthcare organizations that haven’t yet implemented a revenue integrity program. The sooner you start your program, the sooner your revenue cycle can begin performing at its peak.
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