Revenue Integrity: Analyzing and Reporting

In the healthcare industry, as with an industry involving business units, it’s common to see gaps form between clinical operations, coding teams, and patient accounting. This is a universal issue and not necessarily the fault of any one system. As a best practice, revenue integrity can be used to bridge some of these naturally occurring gaps.  

What is Revenue Integrity?

According to HFMA, “Revenue integrity focuses on better coding and charge capture, in particular, to reduce the risk of noncompliance, optimize payment and minimize the expense of fixing problems downstream with claim edits.” Simply put, revenue integrity is in place to enhance the healthcare provider’s margin and protect its overall mission. 

Over 15 years ago, the healthcare industry and its systems started to evolve to what they are today – focused more on value-based and risk-adjusted models for pay. Any changes that come, including Medicare’s HCC changes, have only expanded the need for precision in every step of the process. 

While there will always be many objectives a hospital wishes to see from revenue integrity, the main goal is to combine all departments into one cohesive and flowing unit that maximizes profitability. The aim is to streamline the data and processes to avoid errors or duplication of tasks. 

Leveraging the Right Skill Sets

Regardless of the revenue integrity team’s resources or size, clinical experience is crucial in leveraging the correct skillsets. Acting as the glue between clinical operations and the billing department, revenue integrity teams coordinate all of the claims process elements. This blend of skill sets necessitates clinical expertise from nursing staff with various designations and experience with EMRs, like Cerner and Epic.

Compliance, analytics, business intelligence, and overall workflow optimization are necessary for a successful revenue integrity program. From quality assurance statistics to billing report trends, clinical operations, and how everything impacts revenue, there must be extensive knowledge to minimize errors and ensure everything works together. 

Reports Needed for Revenue Integrity 

By customizing specific data, information, and views to the reports needed, revenue integrity teams can immediately visualize their data. 

Depending on the report, there could be many factors to examine. When looking at an Aged Trial Balance (ATB) report, focusing on the aging claims’ specific data points and demographics is critical. The ATB report helps identify payer denial changes and trends. 

With a Denial Type by Payer report, the goal is to see an appeal or denial within a specific insurance company. Take a deeper look at these reports to understand better what to look for and how their various metrics impact revenue integrity.

How to Analyze Revenue Integrity Reporting

The reports mentioned above are the first step in getting the necessary information to make data-driven decisions that improve denials, opening the door for immediate revenue recovery opportunities while identifying improvements for prevention.

When reviewing the revenue integrity reports, it is crucial to use dashboards and real-time data to identify trends. From the trends, the team can conduct root cause analyses and understand why issues occurred and how to fix them in the future while identifying opportunities that require education, action plans, and process improvement.

Tracking KPIs and progress toward KPI goals is also significant in identifying and improving the billing process’s insights.

How Optics Can Help Revenue Integrity

Advent Health Partners’ Optics reporting platform combines claims and denial data with clinical and IT expertise, which delivers reports on claims trends and root cause analysis. A centralized revenue cycle BI platform combines real-time ANSI X12 EDI 835 and 837 claim, denial, and appeal data from the given sources. Blending data with expertise provides the reports and data needed to help in the claims management process. 

Advent Health Partners also offers revenue integrity consulting, providing root cause trends and actionable recommendations so that the company can start leveraging these proposed strategies immediately. For more information on how Advent can help, schedule a 20-minute consultation today.