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:
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.
During the last week of June, the U.S. Supreme Court unraveled the 1984 decision Chevron v. Natural Resources Defense Council. Chevron has been one of
In 2019, the nursing home industry was relatively stable, generating $126 billion in net revenue, with a profit margin of about 9 percent. However, recent
Please log in to your account to comment on this article.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
This webcast, presented by Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, a recognized expert with over 30 years of experience, offers essential strategies to improve outpatient clinical documentation integrity. You will learn how to enhance the accuracy and completeness of patient records by adopting best practices in coding and incorporating Social Determinants of Health (SDOH). The session also highlights the role of technology, such as EHRs and CDI software, in improving documentation quality. By attending, you will gain practical insights into ensuring precise and compliant documentation, supporting patient care, and optimizing reimbursement. This webcast is crucial for those looking to address documentation gaps and elevate their coding practices.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 ICD10monitor. Powered by MedLearn Media.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
👻Spooky Sale is Back!👻 Get 31% off all three Medlearn brands, using code SPOOKY24.
