What Should a Revenue Integrity Department Look Like?

What Should a Revenue Integrity Department Look Like?

Revenue integrity is a hot topic in healthcare today, and for good reason. The compliance risks of overbilling and the financial downsides of underbilling pose too great a threat for hospitals and healthcare systems. As a result, innovative organizations are creating revenue integrity jobs and departments aimed at better coding and charge capture to ensure compliance, optimize reimbursement and minimize expense.

A 2017 HFMA survey found that nearly 25% of healthcare financial executives consider RI a top priority, and yet only 44% of them have implemented RI programs in their organizations. One reason for the lag is the fact that revenue integrity is still very much a new field that has not yet benefited from standardization. Because of that, many leaders don’t know what a revenue integrity role and/or department should look like in their organizations. They may see the need for a bridge from care to code to charge, but they’re still grappling with how to build it.

Building a Revenue Integrity Department

Start With a Single Point of Contact

The process of developing an RI program may start with hiring a department head who can build out an RI department. The National Association of Healthcare Revenue Integrity (NAHRI) offers tools and resources, including a job description for systems to use when hiring a revenue integrity leader. It’s also a good idea to check out open revenue integrity manager or director positions at organizations comparable to yours when crafting your job description.

Ideally, candidates for your revenue integrity director position should possess the following qualifications:

• Experience in clinical documentation and coding, including strong familiarity with coding of CPT codes and the HCPCS.

• Firm understanding of the Medicare IPPS, OPPS and ASC payment systems.

• Strong understanding of compliance requirements.

• Thorough understanding of the relationship between codes and revenue in the reimbursement process, specifically how revenue is generated from CPT codes and the HCPCS.

Look Outside the Box for Revenue Integrity Experience

Since RI is the new kid on the block, your chances of finding a candidate with previous experience specific to RI aren’t high. The good news is, RI experience can be gained in a range of roles. For the past two years, the NAHRI has surveyed revenue integrity professionals about their roles, titles and responsibilities and packaged up the results in a State of the Industry report. The latest edition, released in June 2019, shows a wide range of backgrounds for RI professionals, including nursing (17%), chargemaster (16%), coding (14%) and patient financial services (10%).

Many RI professionals also hold specialized credentials, the NAHRI found. Just over half of respondents were registered nurses and/or certified professional coders (CPC). Other common credentials included CCS (certified coding specialist) and RHIA (registered health information administrator).

Building From the Ground Up

For better or worse, an organization can have dedicated RI staff without having an RI department. The latest NAHRI report found that while 70% facilities have dedicated RI staff members, only 61% have a revenue integrity department. Even fewer have revenue integrity programs (33%) and revenue integrity committees (22%).

For some organizations, a single staff member may be able to serve as the vital link between revenue cycle, clinical and compliance operations without the assistance of a team. But for most hospitals and healthcare systems, a revenue integrity team is necessary to carry out the various responsibilities related to accounts receivable management, auditing, compliance and education. Forty-two percent of respondents to the NAHRI survey have RI teams composed of two to seven full-time employees. 

The NAHRI survey found that facilities with an RI department were tasked with a variety of responsibilities, including chargemaster maintenance (80%), charge capture (77%), charge auditing (61%), correcting claim edits (55%), denials management (51%) and education (50%).

Radically different responsibilities, ranging from auditing to educating, require a variety of skills. An RI team should collectively possess the following skillsets and experience:

• Familiarity with regulatory changes that impact charging practices

• Strong knowledge of quality assurance processes

• Fluency in data analytics

• Expertise in clinical operations and billing office workflows

• Strong communication skills with physicians and clinical departments

• Proficiency in internal auditing