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The phrase revenue integrity is trending in the world of healthcare and medical practice administration. How can the concept of revenue integrity help your practice?

Revenue integrity is the convergence of reimbursement, ethics, and compliance. Put another way, it is the implementation of protocols to ensure a healthcare organization gets fully reimbursed while meeting regulatory demands and maintaining business ethics.

An approach that gets results

Important insight into this topic emerged from a survey conducted by the Healthcare Financial Management Association and Navigant, a provider of consulting services. In this survey, 125 hospitals and health system CFOs and revenue executives responded to questions on technology use and revenue cycle management (RCM).

Forty-four percent said their organizations have established revenue integrity programs, with 22% of respondents identifying it as a top priority. Among respondents who reported having implemented a program, results were remarkable:

  • 68% report increase in net collections
  • 61% report improvement in gross revenue capture
  • 61% report reduction in compliance risk
While survey participants were from hospitals and health systems, ambulatory practices owners, executives, administrators, and providers face equivalent regulatory pressures and revenue cycle challenges. Compliance risk is a huge concern for any organization that does medical billing, large or small, whether autonomous or part of a health system. No medical practice can afford to follow business processes that allow for errors that may result in significant financial loss or put their very existence at stake. 

Implement a revenue integrity program 

As a first step, your practice can establish its own workgroup to oversee revenue integrity. This workgroup should bring together representatives from clinical practice and business operations. Physicians as well as business leaders should have input into defining the protocols that will take your business to the next level. Participants should be empowered to make change. 

The question such a program seeks to address: Moving forward, what can we do to collect all that we’ve earned while adhering to regulations that govern our practice and maintaining a high standard of business ethics. 

Next, the workgroup needs to determine its parameters and goals. They may decide to meet twice a month for a year, for example. Long-term goals may include lowering costs, reducing compliance risk, or increasing profits by improving efficiency. 

Participants in the workgroup will need a clear view into the revenue cycle. Consider the use of financial and operational analytics software to provide access to business intelligence needed to make informed decisions. 

Establish an agenda

Examples of topics that may be addressed by the revenue integrity workgroup include:

Clinical and operational workflows 
Are your processes easy-to-follow and well-understood by staff? This applies to both clinical and revenue cycle processes. How can you make it easier for staff to be productive while including steps to ensure regulatory compliance?

Costs and staffing 
What are the sources of your more significant costs? Is your practice understaffed or overstaffed? Is staff adequately trained in regulatory compliance and ethical concerns of medical practice administration?

Denial prevention 
Claim denials are a significant cause of lost revenue. Individual denials must be addressed on a case-by-case basis. However, your practice can take steps to understand overall denial patterns. What are the most common reasons for denials—coding errors, errors in patient demographics, failure to obtain proper preauthorization, noncoverage by the insurance plan, lack of medical necessity, or one of many other possible reasons? Once you get answers, you can take steps to improve policies and educate staff. 

Coding and billing practices
Does your practice follow regulatory guidelines on how to process and bill claims and maintain the confidentiality of healthcare information? Are charges are entered and claims sent out in a timely manner?

21st Century Cures Act 
Among other things, this recently enacted law prohibits information blocking. For example, providers must allow patients access to their own data and cannot interfere with the flow of data to other providers and health systems. Is your practice prepared to comply?

Payer analysis 
What is your payer mx? Is it weighted toward government or commercial payers? What is the future potential of your market? Understanding your payer mix will provide insight into business strategy. For example, a practice with a large proportion of government payers that seeks to increase revenue may set a goal to contract with more commercial payers or, instead, may focus on becoming more efficient in submitting claims. 

Consider the role of technology

If your review indicates gaps in your processes for reimbursement, compliance, or both, consider how health IT can be used more effectively. For example, routine processes, such as scheduling, billing, verifying eligibility, claims processing, and assigning follow-up steps can all be automated. Not only does automation increase efficiency; it also frees up staff to work on more ambitious goals of your revenue integrity program.

Automation also be applied to charge review. Custom and specialty-specific rules can be automatically applied to review and correct charge data from your EHR before passing it to your practice management (PM) system. This can prevent denials and catch compliance errors before claims are sent out.

Your health IT also must keep pace with new regulations. For example, with implementation of the 21st Century Cures Act, your patients should be able access their health information from an app of their choice.

The right technology partner should support implementation of protocols that maximize reimbursement while ensuring compliance—empowering your practice’s approach to revenue integrity. 

Meet NextGen Ambient Assist, your new AI ally that generates a structured SOAP note in seconds from listening to the natural patient/provider conversation.

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Marc Miranda

Director, RCM Client Management

Marc is a passionate leader with 10 years business experience leading improvement in physician practices and Federally Qualified Health Centers (FQHC). His work spans across multiple areas of revenue cycle including financial reporting and analysis, payer contracts and value-based risk agreements, PM system implementations and process improvement. He has a CHFP certification from HFMA and a Master of Business Administration (M.B.A.) from Western Governors University. Marc is motivated to improving efficiency and profitability for community health centers so they can deliver on their mission in providing the best care to everyone in their community regardless of their ability to pay.