Revenue Integrity- Is It the Latest Buzzword in Revenue Cycle Management?

In health care, the latest term being used by providers is revenue integrity. Organizations are focusing on the need to address revenue integrity to improve revenues and ensure regulatory and contractual compliance. What do hospitals, physician groups and other providers need to do?–A proactive approach that focuses on rapid assessment and mitigation of risks to your revenue stream should be a key objective for organizations. Here are several thoughts on what to consider in your approach:

Have the right people involved

Although a revenue integrity structure is important, it’s more important that revenue integrity is owned and managed by both the finance and clinical departments that provide patient care and capture the charges for services provided. Well trained staff and a sufficient number of revenue integrity staff are critical to your success.

Have the right tools and processes in placeHave the right tools and processes in place

There are many tools that “ensure” your charge master is accurate and captures all of the charges. However, each of these tools are only as good as the employees using the tools. Many hospitals use charge master tools and think they have a compliant charge master. Unfortunately, these types of tools do not ensure you have an accurate charge master. Areas like laboratory come to mind where a CPT code may be valid but not accurate for the test performed. Charge capture tools that identify missing charges can generate many potential missing charges–they do not generally do a good job in filtering “false positives” that hospital staff can spend a significant amount of time on rather than issues that have significant reimbursement and compliance implications for your institution.

Hospitals need to have a process in place that focuses on the key analytics that drive revenue integrity at their institution for their specific patient and payor population. For example, many hospitals have elaborate charge reconciliation processes in place to ensure that all charges are captured. As most hospitals realize, these processes are too cumbersome for most clinical departments. A simpler approach that focuses on one or two key charge metrics may be a better approach.

Making sure all operating room time charges are captured is a higher priority than making sure every $5.00 supply charge is captured. The overwhelming amount of data available now and in the future related to revenue integrity requires a more thoughtful approach to ensure we look at the data that matters the most.

Monitor revenue integrity and mitigate risk areas

Monitor revenue integrity and mitigate risk areas

Revenue integrity needs to be measured through the tools above to regularly assess your current state. Chart-to-bill reviews and education are key components to minimize your risk areas. A strong group of subject matter experts that can uncover the “hidden” issues in the chart-to-bill reviews and have enough expertise to provide meaningful education to the clinicians is critical to success.

Remember that revenue integrity is not just for hospitals

Remember that revenue integrity is not just for hospitals

As the number of more and more hospitals acquire physician practices, home health agencies and hospices increases, a “hospital centric” approach to revenue integrity is no longer the best approach. Different skill sets, tools and other areas may be required for these types of entities, and things done in hospital revenue integrity may not fit these areas.

When wading through the different approaches and software generated analytics related to revenue integrity, remember that a more deliberate, all-encompassing approach that is specific to your health care institution is the most valuable approach. One size does not fit all when it comes to revenue integrity.

About The Contributor

Mike Kovar, Director 

Mike Kovar has 30 years of extensive experience specializing in revenue integrity. Kovar utilizes his expert knowledge in Medicare rules and regulations, particularly in the Hospital Outpatient Prospective Payment System, to develop effective operational and revenue capture strategies for acute providers.