Revenue Integrity and the Complexity of the Job at Hand

By Brenda Ray, CCS, CCS-P, COC; AHIMA-Approved ICD10 CM/PCS Trainer

Recognizing the hardworking revenue integrity professionals, during this Revenue Integrity Week ─ We applaud you all, and your dedication to address the complex challenges of your profession.

​Surprisingly, many still view revenue integrity as pertaining to just the billing and HIM department. Though important, these areas are simply pieces of the complex business of ensuring data accuracy and regulatory and contractual compliance with revenue integrity. 

HIM and Billing departments are critical to Revenue Integrity, as are other clinical areas such as Infusion, Pharmacy, Laboratory/Pathology, Interventional Radiology, and Radiation Oncology, just to name a few!
 
The fundamentals of revenue integrity are predicated on the realization of data accuracy and compliance for patient service and care and must be performed efficiently. How to achieve this is the age-old question in healthcare. For healthcare entities, revenue integrity requires cohesive processes that link numerous functions from pre-registration to payment processing, including claim denial management. These processes must incorporate clinical documentation, coding, complete and accurate charging, and clean claim submission through an all-encompassing streamlined approach.
 
Compliant charging and billing, accurate charge-capture, appropriate reimbursement, and medical necessity guidelines; are all vital on their own but functioning cohesively together is the secret sauce to a successful Revenue Integrity Program. A primary objective for any Revenue Integrity program is cultivating harmonious workflows between clinical and operational teams that generate accurate charge capture at the initial point to avoid the need for repeated edits. Though processes vary from one organization to the next, the checks and balance in place prior to billing is essential. Regardless, issues will sneak by pre-bill edits and then come back as a denial, making denials management part of revenue integrity. Claims data is critical to many aspects of healthcare, and it’s important for trending issues as this data sets future payment rates and can affect third-party premiums.
 
Being fully compliant with coding and billing practices can reduce the risk of external audits and even payment denials, but you must be intentional in your processes and follow-up. Combining best practices and then optimizing with the right technology proves an efficient way to bridge clinical, coding, and operations to deliver results for an organization. In brief, providers must identify all issues causing revenue leakage or presenting compliance and financial risks. Once identified, preventative measures must be put in place, and department-wide education conducted along with effective remediation processes to stop reoccurrence.
 
Staying the course to achieve revenue integrity will require a focus on bridging the gaps between clinical operations, coding teams, and the business office and has to be a continual process of improvement, as ensuring the integrity of medical data is essential to healthcare.
 
Thank You to all that encompass the Revenue Integrity Teams in Healthcare!
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​As a reliable and trusted firm in the Revenue Cycle space, Axea Solutions services focus on safeguarding healthcare providers' financial situation by facilitating the seamless flow of clinical and administrative functions.

Axea collaborates with partners to provide needed tools to improve the overall Revenue Cycle and support Revenue Integrity. Please visit our services page to see some of the solutions we provide in this space to enhance clients’ financial performance.