What is Revenue Integrity?

Healthcare systems that struggle to achieve the financial margins that allow them to deliver high-quality care may face another significant challenge behind the scenes: the increasingly complex process of diagnosis coding.

In the 1990s, diagnosis coding began to grow more complicated and continued to evolve with the addition of hierarchical condition categories (HCCs) in 2004. Then, in 2015, The Centers for Medicare and Medicaid Services (CMS) mandated the U.S. healthcare industry transition from the ICD-9 to ICD-10.

Hospitals have been mitigating revenue cycle compliance risks of inaccurate billing while also ensuring they are not underbilling for services that have been delivered. Plus, the siloed nature of hospital operations—with clear divisions between the people, processes and platforms in the clinical, coding and revenue cycle departments—doesn’t lend itself to easy solutions.

That’s where revenue integrity (RI) comes into play.

What is Revenue Integrity?

Increasingly, hospitals are creating revenue integrity careers and departments to prevent compliance risk and revenue loss. The goal of RI, according to the National Association of Healthcare Revenue Integrity (NAHRI), “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.”

Most every hospital CFO recognizes the need for revenue integrity, but many hospitals are still tinkering with how RI fits into their organization.

According to a 2017 HFMA survey of 125 hospital and system financial executives, 22% identified RI as the leading priority for their organizations, but fewer than half of those respondents (44%) have established RI programs.

For those healthcare systems that have developed RI programs, the results are significant. 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.

Establishing an RI program improves workflows and creates a knowledge base inside the organization to help medical coding and revenue cycle professionals operate more effectively. RI programs typically act as a bridge between clinical, coding and revenue cycle operations.

Ensuring the integrity of coding and billing is accomplished by RI team members with various skill sets and expertise, so they can smoothly adapt to the workflows of each of these separate functions. RI teams comprised of various skillsets, registered nurse, coders i.e. are able to validate the patient’s condition and subsequent care delivered are properly coded and charged.

For many hospitals, RI is viewed as an evolution of current efforts to lessen compliance risk and increase revenue. It usually means establishing improvements across three areas:

Process: Most systems have their clinical operations siloed from coding, and revenue cycle siloed from coding. RI develops new workflows to mitigate compliance risk and increase reimbursement while honoring existing, functional workflows.

People: Without RI, employees operate in their own specialty and are trained in one of three defined functions: clinical, coding or revenue cycle. With RI, teams of people lend specialized understanding to efforts to work together and ensure that efforts are aligned toward the appropriate goals.

Platforms: Only recently have specific technologies developed to bridge data gaps and aid more congruous workflows between clinical, coding and revenue cycle departments. RI platforms connect siloed data, and increasingly, artificial intelligence (AI) and machine learning optimize RI efforts.

The need to break down the silos between clinical, coding and revenue cycle departments are leading forward-looking healthcare systems to adopt RI. Maintaining your hospital’s mission means achieving margins and doing so in compliance, and providers can turn to revenue integrity to help accomplish outcomes.