What is Revenue Integrity and Why Is it Important?
Revenue integrity offers healthcare organizations financial stability to continue to provide patient care.
From labor shortages to slim operating margins, U.S. hospitals have faced increasing challenges over the past few years. The solution is for healthcare organizations to focus more on revenue integrity, so they may find financial stability and combat the challenges of today's healthcare climate. Let's take a deeper look at what revenue integrity is and how it can benefit your hospital.
What is Revenue Integrity?
Revenue integrity involves accurately capturing charges, correctly coding and billing services, and ensuring that claims are submitted and paid according to constantly changing regulatory and contract requirements. This is so your healthcare organization accurately reflects services provided through charge capture and receives correct payment for patient care in a timely manner.
6 Components of Revenue Integrity
Revenue integrity isn’t a one-step process. It’s actually quite complex. To prevent revenue leakage, hospitals must update protocols and correct issues in every department, and in a personalized way. To ensure integrity and maximize revenue, get to know the following components of it:
1. Clinical Alignment
Clinical alignment involves hospitals partnering with clinical departments to better understand the services these departments provide and to educate them on the documentation needed to support charging for those billable services. Successful hospital-physician alignment and hospital-clinician alignment requires mutually identifying goals and establishing an integrated system to deliver high-quality, cost-effective care.
2. Charge Capture
Charge capture is the complex process of healthcare workers accurately documenting services, procedures, and supplies that they provide to patients while under their care. This requires comprehensive documentation, leveraging the EHR to trigger charges, and applying rule-based logic to accurately capture the services rendered to patients while under the hospital's care.
Once discharged, hospitals send those charges for reimbursement, and if medical services aren’t properly documented and/or that documentation does not translate into accurate charging, hospitals lose revenue.
3. Coding and Billing
Coding involves translating every patient's medical history and treatment into standardized alphanumeric codes. Doing this accurately, by following coding guidelines and billing regulations, minimizes errors and helps hospitals obtain accurate reimbursement and avoid potential penalties.
4. Payer Contracts / Reimbursement Awareness
Payer contract management ensures healthcare providers are paid correctly and on time, following contract terms. It requires overseeing contracts to ensure reimbursements are accurate. To fully understand how payer contracts impact the hospital's bottom line, it's essential to understand the current payer contract and reimbursement landscape as well as the impacts of contractual language.
A true revenue integrity function will support payer contract negotiation, providing input into what can be operationalized for documenting and charging to obtain reimbursement and analyze changing service patterns.
5. Claims Management
Claims management is the handling and overseeing of healthcare claims' submission, processing, and reimbursement. It guarantees that claims are accurately prepared, submitted on time, and compliant with regulatory requirements to maximize revenue for healthcare organizations. Efficient claims management minimizes claim denials, reduces revenue cycle delays, and optimizes reimbursement rates.
6. Data Analytics and Reporting
Hospitals can't fix what they don’t track. By collecting data, hospitals can help identify patterns in their revenue cycle, so they can better understand what initiatives improve their net revenue and which ones do not.
Examples of the most important analytics for a revenue integrity team include the following:
Late charges
Charge-related denials
Coding conflicts
Charge reconciliation
Cost reporting/ utilization
Why Is Revenue Integrity Important?
Ineffective processes throughout the revenue cycle cost healthcare organizations billions of dollars annually. United States clinicians lose approximately $125 billion each year due to inaccurate or incomplete documentation, coding, and billing practices, which clearly puts hospitals under financial strain, and most importantly, negatively impacts patient care.
By ensuring accurate reimbursement for services rendered, hospitals can allocate resources more efficiently, invest in staff training and development, and ultimately improve patient care outcomes.
3 Strategies for Improving Revenue Integrity
1. Understand Your Current Situation
To optimize your hospital's financial health, you must first understand every component of your revenue cycle and identify areas of weakness or inefficiency. Conduct a thorough assessment of services provided in each department, documentation practices, workflows and system capabilities for charge capture, coding and billing processes, payer contract alignment, claims management, dictionary maintenance, and data analytics practices. Assess potential blind spots and ask yourself if you have the necessary resources to correctly and effectively complete each task and process.
2. Educate Your Team
A well-informed staff is one of the best tools for fighting revenue loss. Educate them on the importance of revenue integrity and conduct regular training sessions on the latest documentation requirements, billing codes, internal processes, and compliance regulations. It’s critical to the health of your hospital to invest in ongoing education so that they’re empowered to navigate complex billing scenarios confidently.
3. Work With an Outside Partner
Optimizing revenue integrity requires a nuanced approach and is specific for each hospital. A strategy that worked well for one or more healthcare organizations may not be ideal for yours. Working with an outside partner like Eclipse Insights, can help ensure you implement a solution customized to your organization’s specific needs. Our custom analysis identifies your hospital’s specific opportunities for improvement, helping to quickly increase your net revenue and ultimately, patient care.
Your Revenue Integrity Partner
Optimizing revenue integrity improves your hospital's financial stability, allowing you to provide better patient care. However, identifying and prioritizing areas for optimization alone is overwhelming and inefficient. Eclipse Insights is your revenue integrity partner, helping you every step of the way. Contact us today to learn more about our services. We're eager to help your healthcare organization, and the people who need your services, thrive.
