Revenue Integrity Delivers Critical Impact to Revenue Cycle Management

Revenue Integrity Delivers Critical Impact to Revenue Cycle Management

A strong revenue integrity (RI) program can help revenue cycle departments preserve the margins that further the mission of delivering high-quality healthcare. RI programs accomplish these ambitious goals by mitigating the compliance risks of inaccurate billing while also ensuring hospitals are not underbilling for services that have been delivered. And the C-suite is paying attention: In a 2017 HFMA survey, hospital CFOs identified revenue integrity as the most important priority for their organizations.

Healthcare systems that have developed RI programs see significant results. More than 68% of executives surveyed reported increased net revenue collections, with 61% reporting an increase in gross revenue collection. In addition, 61% reported a decrease in compliance risk after establishing a RI program.

Organizations can expect these benefits from the implementation of RI programs:

  • Higher clean claim rates
  • More proactive identification and resolution of claim issues
  • Increased reimbursement

RI programs serve to bridge gaps between clinical, coding and revenue cycle functions. The best RI programs are proactive, with the goal of improving workflows and creating a knowledge base inside an organization to help revenue cycle professionals operate more effectively.

Here are three specific ways a RI program can help revenue cycle departments:

1. Managing A/R

Accurate coding and the development of clean claims all have an impact on A/R on the back end. Revenue integrity teams can study revenue cycle analytics, such as days of aging A/R and unbilled days, to identify problematic trends with coding or billing, perform root cause analysis and subsequently develop solutions.

Identifying patterns, a process increasingly aided by artificial intelligence, helps the RI team solve key questions, such as:

  • Why are there delays in claims processing?
  • Why are repetitive edits occurring?
  • Where can manual interventions be eliminated?

2. Auditing to ensure accurate charge capture

Revenue integrity audits can help improve coding and billing, optimize reimbursement revenue, and get rid of unnecessary aging A/R. RI teams check for compliant coding and clean claims in an effort to steer clear of overbilling or underbilling for services that have been delivered. RI teams use auditing as a tool to help deliver performance feedback and prevent the cost of claim edits or unnecessary collections.

3. Delivering education and proactive process improvements

RI teams can identify knowledge gaps and provide helpful feedback and expert training where those gaps exist. These teams can also develop training materials and continuing education resources to help revenue cycle management professionals improve their skill sets.

Forward-looking health systems are strengthening every chain in the revenue cycle, and RI programs are part of those efforts.