The Importance of Clinical Expertise in A Revenue Integrity Partner

When considering engaging a revenue integrity partner, it’s essential to focus on three main components: clinical expertise, the right technology, and proven client success, but for this article, we will focus on clinical expertise.

Clinical expertise is critical in solving clinical and coding review challenges. Some important qualifications include: 

  • Having a team of industry veteran nurses with multiple years of experience on both payer and provider sides
  • A team of credentialed coders to conduct reviews
  • A variety of healthcare designations, including LPN, RN, MSN, CRNAC, and more
  • Experience with various EMR platforms, including the most frequently used, such as Cerner and Epic
  • Expertise with clinical operations and billing workflows
  • Fluency in data analytics to proactively address growth challenges

An experienced clinical team can determine the viability of every claim placed, craft quality appeals, and follow up appropriately for revenue recovery. Data is vital in this industry, but data alone fails to address underlying causes and solutions without proper analysis. An experienced team can take the data, ascertain the root causes for clinical denials, and recommend and implement best practices related to the root cause and process improvements. 

A properly trained team is also able to report on progress toward KPIs in strategic business meetings. If the goal is to achieve a more efficient time-to-revenue ratio, an experienced team that focuses on steadily improving KPIs and a shorter time to reimbursement is critical. 

While being skilled in denial management can be valuable in a revenue integrity partner, it falls short when considering both payer and provider perspectives. Overturning appeals and managing backlogs becomes more difficult without understanding the full scope of medical necessity due to the many factors that go into overturning appeals and properly handling denied claims. 

Well-trained revenue integrity staff and a good support system are critical to the success of any hospital and health system. Beyond bridging current gaps, an experienced team can provide information and best practices to solve core business issues. When combined with technology and a commitment to client success, appropriate and timely reimbursement will follow.

Advent Health Partners provides solutions to the challenges providers face in today’s healthcare environment. To see if it’s the right fit, schedule a 20-minute solutions consultation with a team member today.