The pandemic has brought about massive, global changes for every industry, including the healthcare sector which has been severely impacted. While the pandemic has pushed digital transformation in healthcare ahead by several years, the challenge to keep technology tied with processes is still an ongoing effort.
In the case of healthcare, there is an added struggle - to achieve financial margins. When the number of patients only increased, there were significant challenges behind the scenes: remaining efficient and optimizing the reimbursement/payment process while being compliant. And this is how the term Revenue Integrity (RI) became the talk of the town!
The Importance of Revenue Integrity
As per the National Association of Healthcare Revenue Integrity, the goal of Revenue Integrity is to “prevent recurrence of issues that can cause revenue leakage and/or compliance risks through effective, efficient, replicable processes and internal controls across the continuum of patient care, supported by the appropriate documentation and the application of sound financial practices that are able to withstand audits at any point in time.’’
In simple terms, revenue integrity is critical to ensure no leaks by optimizing the revenue cycle, being compliant, and making the processes efficient. While the three - billing, operations, and compliance - have always been independent departments, getting these disparate entities to work together is the focus of revenue integrity. It creates a seamless experience in the clinic for patients, healthcare coding in the backend, and tying it with the revenue cycle.
However, prioritizing revenue integrity is easier said than done, with diagnosis coding growing more complicated as time goes on. One of the most recent changes occurred in 2015, when the Centers for Medicare and Medicaid Services mandated the US healthcare industry to transition from the International Classification of Diseases Clinical Modification, 9th revision (ICD-9) to ICD-10. On top of that, coding, billing, and revenue cycle departments remain separated from each other, adding another layer of complexity to ensuring compliance.
With juggling compliance risks of inaccurate billing and managing accurate payments to prevent underbilling, providers are turning toward revenue integrity to help streamline the process. Providers are creating RI departments or looking to hire RI specialists to prevent compliance risk and revenue loss.
Establishing an RI program or plan creates a bridge between the siloed sections of a hospital including operations, compliance, and billing departments. Not only can this improve the workflow, but it also helps to prevent any revenue leakage that may occur from inaccurate billing. By focusing on revenue integrity providers reduce the risk of external audits and help reduce payment denials. With an efficient RI plan in place, providers can achieve their financial margins while working within compliance.
Optimizing Revenue Integrity by Preventing Leaks
Some reasons for leaks:
- Coding errors are the number one reason Medicare and Medicaid deny complex claims that can impact reimbursement.
- Manual transactions - the possibility of errors is always high. Data suggest providers end up paying $4.77 more per claim.
- Patient accounting system - outdated systems can slow down the processes, and providers will lose crucial time.
- Rejected claims - rejections because of one or more errors take up critical time and multiple entries on the system.
By being compliant in coding and billing practices, providers can automatically reduce the risk of possible payment denials - which saves both time and money. For healthcare where billing numbers are high, such errors and leaks can cost a lot. Also, it affects the experience for a patient and can become a problem in the longer run.
Revenue Integrity Best Practices
Creating a plan is the first step to focusing on revenue integrity. This includes setting up guidelines and procedures that anyone involved in revenue will need to follow. Revenue integrity involves balancing the goal to increase revenue with the responsibility to comply with the rules. Here are a few steps to start an RI plan:
Access Current Workflows
Review each workflow and input involved in revenue integrity from operations to billing. Ensure that each workflow is efficient and compliant, paying particular attention to the claims workflow.
After doing a thorough sweep of workflows, consider what could be improved and how best to allocate resources. Make sure that all key processes are functioning efficiently and optimally including utilization review, coding, charge capture, and claim editing. If they're not, find the reason why and take steps to ensure processes function optimally.
Managing Denied Claims
It’s no secret that denied claims contribute to revenue leakage. Ensure that the denials management process is efficient and accurate to confirm that denied claims are being handled properly.
Technology and business automation are constantly improving and it's easy to continue functioning without realizing an antiquated system is slowing processes down. By looking at the technology the hospital uses with a critical eye, providers may find some inefficiencies.
Not all providers have time or resources to put together an RI program. Involving revenue integrity services might be the better option. Services such as Exela’s Revenue Integrity solution help providers maximize reimbursement from third-party payers, identify and recover underpayments, redistribute overhead related to in-house staff, and provide a more streamlined process.
For more information on reducing revenue leakage and the importance of Revenue Integrity, read the latest PluggedIn edition.