A solid revenue integrity program encompasses all areas of the revenue cycle. It includes processes to prevent revenue loss or delay and, if implemented correctly, can also increase revenue, provide higher clean claim rates, and improve compliance across the revenue cycle. With healthcare revenue cycles growing in complexity and battling constant healthcare policy changes, healthcare leaders across the industry are honing in on revenue integrity to help solve and prevent revenue issues that lead to revenue leakage.
What is Revenue Integrity?
According to the National Association of Healthcare Revenue Integrity (NAHRI), revenue integrity (RI) can be summarized as:
The basis 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.
Is 'Revenue Integrity' just a new buzzword?
Over the past decade, hospital merger and acquisition activity has increased significantly, and in return, we've seen a growing emphasis on operational and financial efficiency. In the pursuit to improve productivity and operating margins, healthcare organizations are now considering how those in roles related to compliance, medical coding, patient financial services, and chargemaster can have more impact by developing revenue integrity programs.
Revenue integrity might be a new field, but the benefits make RI more than a buzzword, especially considering the number of healthcare executives that state RI as a top priority. A 2017 HFMA survey found that nearly 25% of healthcare financial executives consider RI a top priority, yet only 44% of them have implemented RI programs in their organizations.
Of the hospitals and health systems with a revenue integrity strategy in place, about 68 percent reported that a revenue integrity program increased their overall net collection, and 61 percent stated that it improved overall gross revenue capture.
What are the benefits of revenue integrity?
As hospitals and physician practices continue to face accelerating expenses and shrinking bottom lines, revenue integrity can lead to RCM benefits such as:
- Reduced accounts receivables
- Improved management of claim edits and denials to speed up cash flow
- Standardized processes that reduce repetitive problems
- Enhanced compliance across the revenue cycle
- More accurate charge capture
Building a Revenue Integrity Program
Because RI is relatively new, getting started can seem overwhelming. We recommend starting your RI program by analyzing your revenue cycle management today. This will help you identify gaps and problem areas today and help you identify goals for the RI program.
Once you've established short term and long term goals, the plan, and the vision, begin mapping out the functions you need. The map should include the number of resources necessary, the departments these resources report to within your organization, and where you might be able to make changes to current roles and resources or hire new.
Like any program, you'll also need to define the expectations and ongoing processes to monitor each role's success and the program as a whole. As you look at how to monitor your revenue integrity program, consider key metrics across medical coding, collections, and denials. Metrics like clean claim rate, first-pass resolution rate, denial volume as a percentage, denial appeal success rate, charge capture lag time, and incomplete or missing charges are just a few metrics that can assist you in gaining initial insight into your revenue integrity program. Depending on your organization and RI goals, you may need to track additional metrics.
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