Revenue integrity (RI) is a buzzword that can mean different things for different organizations, but in healthcare, the definition is specific: to ensure that every clinical encounter is translated into revenue, using methods that focus on operational efficiency, compliance, and optimal compensation for services. Here’s an overview of RI in healthcare and best practices for maintaining it.
Overview of RI
According to the National Association of Healthcare Revenue Integrity (NAHRI), 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.”
Traditionally, operations, compliance, and billing departments are siloed — with clear divisions between the people, processes, and platforms in the clinical, coding, and revenue cycle departments. That setup doesn’t lend itself to easy solutions. Getting these disparate entities to work together throughout the continuum of a patient’s clinical experience is an important goal for optimizing Revenue Integrity.
According to a 2017 HFMA/Navigant Consulting survey of 125 health system executives, nearly 22% cited Revenue Integrity as a top priority, but only 44% have established programs. However, those that have implemented an RI program have seen significant increases in revenue collection.
Revenue Integrity best practices
Healthcare practices and hospitals that want their operations centered around Revenue Integrity need to create a plan and set up guidelines and procedures that practitioners, coding and billing staff, and anyone else involved in revenue need to follow. Here are some best practices for setting up those guidelines:
- Analyze all components and processes of your workflows, from clinical operations to billing, to ensure they are integrated, efficient, and compliant.
- Ensure key processes such as utilization review, coding, documentation, and charge capturing are functioning optimally.
- Claim denials cause significant revenue leakage; be proactive in denial management.
- Ensure greater transparency into the components of your revenue cycle to ensure they are integrated and working toward the same goals.
- Have an outsider review the elements of your revenue cycle to ensure it is running as efficiently as possible.
- Review your current technologies to make sure they are up to date.
- Employ tech solutions that provide insights you can use to make predictions and take appropriate action. For example, automated revenue cycle management solutions can free up staff so they can focus more on patients. Automatic scanning can enable staff to analyze coding before submitting claims to reduce denials. Increasingly, artificial intelligence (AI) and machine learning are being used to optimize Revenue Integrity efforts.
Fitting Revenue Integrity into your organization
The first thing you have to decide when bringing an RI program into your organization is who will be in charge of the program. Each area — clinical, compliance, and revenue — has different skill sets. It’s important to have a leader or department overseeing RI and integrating all elements and workflows. Often it’s better to bring in a third-party organization to oversee an RI program, especially if you lack the staff and resources. By partnering with an organization experienced in the various elements of the revenue cycle and Revenue Integrity, you can ensure an objective perspective.
TruBridge can give you an outsider’s objective perspective on your organization’s Revenue Integrity efforts. We can also provide current technologies, expertise, and best practices to ensure that all the elements driving RI are working together to realize the best outcomes. Contact us today to get started.
Written by Cassie Wise
TruBridge Executive Director