Strategies for Fine Tuning Revenue Integrity

By Elaine Dunn and Vindali Vartak

There’s a lot of talk about healthcare organizations needing to improve revenue integrity to ensure compliance and realize strong financial performance amid changing payment models. But what is revenue integrity exactly, and how can organizations go about enhancing it?

Fundamentally, revenue integrity involves making sure that everything that happens from a revenue standpoint during the space of a clinical encounter is accurately captured and translated into a claim. There is a common misperception that revenue integrity is a combination of discreet revenue cycle or health information management (HIM) functions. However, it is really an outcome. To realize optimal revenue integrity, all the front-end, middle, and back-end processes that drive it must be addressed collectively with the outcome of revenue integrity in mind.

How can organizations achieve this level of performance? Here are six strategies for getting started.

1. Take stock of the current state. A first step is to closely review every one of the inputs that contribute to getting a compliant, correct, and complete claim out the door and look for potential blind spots. Do you have the right resources in place to effectively execute each task and process? Are you following best practice in terms of technology, staffing, and workflow? Are the various components integrated and aligned? Where do you lack insights to inform decisions and how can you start collecting that information? The answers to these questions will help you begin to build an action plan for improvement.
2. Shore up the middle. Historically, revenue cycle operations have been focused on front-end patient interactions, back-end billing processes, and bad debt management. However, what occurs in the middle of the revenue cycle—from the point of the clinical order through getting the service on the claim—hasn’t received as much attention because organizations up to this point have been paid on a percentage of charges through fee-for-service structures. For this reason, there hasn’t been a huge driver to optimize the middle part of the revenue cycle. But now that the industry is moving towards value-based care and bundled payments, and payer requirements are becoming much more complex, there is an increased need for attention in this space. To preserve revenue integrity, organizations must make sure key activities like utilization review, documentation, coding, charge capture, and claim editing are functioning at the highest level. There also should be greater transparency between this middle area and the rest of the revenue cycle to ensure every element that can impact revenue integrity is integrated and working toward the same goals.
3. Double check your perspective. Once you have internally reviewed your processes and workflows, it can be helpful to get an objective set of eyes to audit the current state. A good partner will verify that the output of each phase ensures revenue integrity and optimizes processes and resources across reimbursement models while maintaining compliance.
4. Review current technology with a critical eye. Make sure you take a hard look at the technology you have in place. Over the last decade, the industry has seen an evolution in electronic health records (EHRs) and what the technology can do. That said, organizations should be realistic about what the EHR can truly deliver and where they should augment or supplement. This is especially important with regards to documentation, coding, and charge capture. Layering some best-of-breed solutions on top of the EHR can ensure you are pulling the full value out of an encounter and that processes are flowing smoothly and efficiently.
5. Seek out tools that provide actionable insights. When considering technology solutions to pair with an EHR, it is important to look for systems that provide succinct and informative recommendations based on historical data, and that allow you to rapidly address integrity concerns or stop potential leakage on a go-forward basis. There is no shortage of data in healthcare and without tools to sort through it and pull out actionable insights, an organization can quickly become inundated and overwhelmed. You don’t need another table or pie chart. Action-driven insights tell you how to manage the economics of your revenue cycle. In some cases, a solution may use emerging technologies, such as artificial intelligence (AI) and natural language processing, to efficiently and effectively uncover meaningful patterns. Note that all AI-based tools are not the same. A solid solution learns best from rich payer and provider data. The more robust the data, the better the solution is at uncovering insights and making reliable predictions, which users can use to take decisive and appropriate action.
6. Consider working with an outside partner. Preserving revenue integrity requires a multifaceted strategy that includes both technology and people solutions. While hospitals and health systems may be able to navigate this effort on their own, they often find partnering with a third-party resource to be advantageous. The ideal partner has both the technology chops to deliver valuable insights and access to knowledgeable experts who can implement best practice. By working with such a partner, organizations can be confident that all the functions driving revenue integrity are working as they should and helping the organization realize solid outcomes and strong financial performance.

Elaine Dunn is vice president of Revenue Integrity at Change Healthcare. Vindali Vartak is senior director of Advanced Analytics at Change Healthcare.