Does Your Healthcare Organization Need a Revenue Integrity Program?

December 14, 2022
Healthcare Organization

“Revenue Integrity” programs aren’t a new concept, yet they’re gaining popularity as healthcare organizations struggle to improve bottom lines. Preventing revenue leakage that can result from inaccurate codes, charge capture issues, improper chargemaster set-up all are contributing factors to rejected claims and opportunities for lost revenue. Many are realizing that costly rework from returned or rejected claims can be minimized with the implementation of a revenue integrity program.

At many organizations, the revenue integrity function is performed disparately and isn’t streamlined for efficiency. Having a centralized revenue integrity program or department helps decrease the loss in revenue (i.e. revenue leakage) by providing focused oversight and dedicated resources for clinicians in the revenue generating departments. Having this level of focus and resources allows organizations to work towards ensuring charges are set up properly and being captured and coded and billed accurately leading to more timely and potentially more capture of reimbursements they’re entitled to, improving the overall healthcare revenue cycle.

What Does a Revenue Integrity Program Do?

A revenue integrity program is meant to validate the integrity of data that flows from the clinical and coding/charge capture systems into the claim itself, ensuring it is accurate and complete. Whether you operate a small or large organization, such validation is essential to ensuring charges and codes are captured accurately and compliantly before sending claims to payors.

These functions not only check the integrity of data but will work backwards to correct any issues along the revenue cycle for continual improvement and accuracy. Revenue integrity analysts will perform checks and balances to evaluate systems and processes are performing accurately and appropriately. They will also act as liaisons between business office and clinical functions, working to ensure their tools and systems work appropriately so they can perform their jobs efficiently.

If they identify an issue with a system or process meant to capture a charge accurately isn’t doing so, they investigate the root cause and work to determine a solution to the problem. All of this equates to less time spent on manual fixes, rework or missed charges while shortening the time from services being performed and charged to claim submission.

When functions operate as they’re supposed to, and the revenue cycle team isn’t caught up fixing claims and emailing clinicians to enter charges, the process is more streamlined and reliable. Without such a department, your revenue cycle process might be inefficient, with excessive rework that stops the continuous flow of information and limits productivity.

Signs You Need a Revenue Integrity Program

If you assess your processes and operations, you’ll likely discover inefficiencies along the revenue cycle chain that warrant the development of a revenue integrity program. Some indications are more critical than others, such as:  

High Rate of Denials

Organizations with a high number of denials from all types of payors typically need a team dedicated to identifying and resolving issues so they can resubmit claims. If you lack such personnel and do not have a denials analysis and management function which can look at root cause and resolution, you could end up writing off many claims resulting in lost revenue.

Low Clean Claims Rate

The clean claims rate can be accessed and assessed prior to the claim going to the payor. If it is low, this is an indication that your organization is submitting claims with errors that then require fixes after submission to the clearinghouse, but prior to submission to the payor. It’s important to identify upstream issues that are causing errors to improve accuracy sooner in the process.

Many Manual Fixes Along the Way

If you have multiple individuals performing manual fixes to claims along the way, you may get clean claims out the door and avoid denials, but this high amount of activity extends the time from the date of service to the time it’s billed.

Dispersed Revenue Integrity Function

In many cases, the revenue integrity function is performed piecemeal across departments by various individuals. This leads to silos, as well as redundancy in rework and lag time that could otherwise be avoided. Further, rework often takes individuals away from their main job duties, causing productivity issues.

Building a Revenue Integrity Program

The revenue integrity program may be distinct from other departments, or it may be housed within another area such as patient financial services or coding. This decision depends on the size and structure of the organization. In larger organizations, the leader of this area may report up to a role equivalent to the VP of Revenue Cycle.

Revenue integrity analysts should report to the revenue integrity leader as a group. Denial’s analysis and management could roll up under the leader of revenue integrity. These individuals might have coding or billing backgrounds (a blend of both works well) that enable them to tackle complex denials. The chargemaster set up and maintenance function should also fall under this area.

Ideally, you should have analysts designated to support specific departments. For example, an emergency department revenue integrity analyst will be knowledgeable about the chargemaster set up for the services performed in the department, how the charges are captured, and how the coding is done for the department.

For your revenue integrity program to be effective, it’s critical to document work performed and related communications and maintain them in some sort of log or shared filing system. This will ensure history of discussions, changes, etc. made will be documented and in one location.

Making the Case for a Revenue Integrity Program

We often recommend implementing a revenue integrity program because it’s critical in preventing revenue leakage while also unifying processes, identifying root causes to at risk claims, provides checks and balances to ensure charges are captured, and creating efficiencies. Such a program eliminates work outside of coders’ job duties, gets correct and accurate claims out the door faster and becomes an internal mechanism for continually improving revenue cycle processes.

Often, healthcare organizations partner with outside advisors such as our Eide Bailly healthcare group into the revenue integrity process to provide an objective opinion and industry-informed recommendations. We are knowledgeable and experienced in various aspects of the healthcare industry, from coding to compliance, which helps us quickly understand your systems and data flows. 

A Revenue Integrity Program can provide peace of mind in minimizing revenue leakage and assist in identifying gaps and inefficiencies in your revenue cycle mid-cycle. Our healthcare advisory team can help you with the initial assessment and implementation.

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