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 Advent Can Help
Apello, our propriety claims analysis technology, intakes and extracts data from medical records while utilizing a proprietary search functionality that allows pertinent data to be extracted at the click of a button without requiring a cumbersome visual review. Apello supports coders, nurses, and physicians in searching for documents supporting the diagnosis sequencing if the DRG assigned is consistent with the documentation and treatment.
Advent Health Partners provides strategic business intelligence reporting through Advent’s Optics reporting platform. Optics gives clients access to valuable, real-time reporting based on previously disparate denial management data. Create intuitive dashboards with Optics’ flexible framework to display insightful information and pave the way to discovering actionable data points to improve denial management and denial prevention programs.