Congruous Workflows: Revenue Integrity’s Aim

Congruous Workflows: Revenue Integrity’s Aim

Think about the smallest physician’s practice, where one person (probably the nurse) is also the one responsible for coding and billing. The lack of specialization poses its own problems, but there’s also a benefit to the same person doing each of those tasks. The left hand always knows what the right hand is doing—because those hands belong to the same person.

When the healthcare industry transitioned from ICD-9 to ICD-10, healthcare systems and hospitals were challenged to meet new coding standards. The challenge was largely due to a lack of coordination between clinical, coding and billing functions. If the same person can’t be in charge of clinical operations, coding and the business office, then these teams must be so closely coordinated that the result is correct coding and charge capture the first time, every time. The siloed nature of the functions results in incongruous, highly disjointed workflows that can lead to denials, delays and increased compliance risk. 

Creating more congruent workflows isn’t just one of the central goals of revenue integrity; it’s the key to unlocking all the additional benefits of revenue integrity—compliance assurance, optimized reimbursement and minimized expense. Here’s how you can start breaking down the silos in your organization to create better, more consistent and congruous workflows.

Assembling a team

If your organization is new to revenue integrity, the first step is assigning someone to be the project leader. Whether this is your revenue integrity director or someone who reports to them largely depends on the size of your organization and the resources currently available for revenue integrity initiatives.

The leader will be responsible for assembling the revenue integrity workflow optimization team, which should include representatives from each department affected. In the case of revenue integrity, this could be a long list of stakeholders, including:

Pre-visit: Patient access, eligibility

Point of service: Coding, utilization review, case management

Back office: Patient financial services, edits, denials

Taking time to document workflows

Avoid making assumptions early in the process. At this point, every part of the workflow should be up for improvement. And it’s impossible to determine which workflows should be improved without first understanding how the various systems work.

Prioritizing workflows for improvement

Once you have comprehensive documentation of clinical and operational workflows, discuss with your team how to prioritize. Consider the size and sophistication of your revenue integrity program before prioritizing too many workflows for immediate improvement. Focusing on quick, easy wins can help generate goodwill for the program and support from senior leadership. Also, take the time to mark workflows that are working as is. Don’t archive them, though, because they may need to change based on workflow improvements made elsewhere.