Revenue Integrity: Leveraging Data to Enhance Collaboration Across the Revenue Cycle Download Summary In today’s complex healthcare environment, hospitals and health systems and other provider organizations have little room for error within the revenue cycle. Faced with tight margins, growing labor and supply costs, and volatile markets, every dollar counts. Revenue integrity ensures all patient encounters are accurately converted into revenue in compliance with applicable laws and regulations. Through revenue integrity, organizations can identify and address systemic processes and procedures that lead to revenue leakage to ensure accuracy and appropriate reimbursement while also improving the quality of care. Health information (HI) professionals have an important role to play in this process. The American Health Information Management Association (AHIMA) and Protiviti convened a panel of HI and revenue cycle professionals to explore best practices in revenue integrity and the role of HI, as well as how organizations can leverage data to enhance collaboration across the revenue cycle. Download Topics Risk Management and Regulatory Compliance Business Performance Data, Analytics and Business Intelligence Expert Panel PANELISTS Mazette H. Edwards, MA, CDIP, CCS Assistant Vice President, Revenue Cycle Northwell Health System NEW HYDE PARK, NY Kimberly Seery, RHIA, CDIP, CCS, CHDA, CPC, CRC Associate Director, Coding and Data Quality Health Information Management Services ChristianaCare WILMINGTON, DE Tami Montroy, MS, RHIA, CCS Director of Central Fee Abstraction University of Pennsylvania Health System PHILADELPHIA, PA Gina Sanvik, MS, RHIA, CCS, CCS-P Practice Director, Revenue Cycle Management & Coding AHIMA MINNEAPOLIS, MN Caroline Znaniec, MBA, MS-HCA, CRIP Managing Director Protiviti WASHINGTON, DC What is Revenue Integrity? Revenue integrity helps bridge the gap between coding teams, clinicians, and the business office. The focus is to ensure all patient encounters are accurately documented, coded, billed, and paid. Today’s provider organizations face numerous challenges that impede revenue integrity, including ongoing revenue cycle and HI workforce shortages, disparate processes and competing priorities within the organization, and the complex, evolving payer and regulatory environment. These challenges lead to breakdowns in the revenue cycle which result in denied claims, significant rework, and lost revenue. While data and analytics and digital tools and automation can address some of these challenges, provider organizations must prioritize revenue integrity to achieve sustainable results. Revenue integrity is not a passive process. It involves formalized, continuous processes to identify and correct issues that lead to revenue loss or pose a compliance risk and ensures accountability throughout the revenue cycle. Through gap analysis, reconciliation practices, data analytics, and education, organizations can understand their pain points and develop consistent policies and procedures to support efficient, effective billing practices. Revenue integrity helps break down silos and promotes shared purpose and learning across all stakeholders, including clinicians, compliance, health information management, and revenue cycle. Revenue integrity is essential to meeting organizational goals and objectives. Decreasing the loss in earned revenue and reducing compliance risks enables organizations to direct more resources toward patient care and improve operational efficiencies. There is no one-size-fits-all approach to revenue integrity, the panel notes. Some provider organizations have formal, centralized departments to assess and enhance revenue integrity across the system, while others take a more decentralized approach at the hospital, department, or practice level. Regardless of the structure, revenue integrity seeks to understand the denial and audit landscape and enhance claim quality. This helps optimize payment and reduces costly, time-consuming downstream fixes. Audits and compliance checks are not substitutes for revenue integrity, the panel notes, because they often fail to identify emerging issues and account for changing clinician documentation practices. These processes are an integral part of the revenue integrity process, however, helping identify compliance risks and ensuring standards and procedures are up to date. "Revenue integrity really focuses on getting the appropriate reimbursement for the work that we do." Tami Montroy University of Pennsylvania Health System Overcoming Challenges to Revenue Integrity The panel highlights top challenges to revenue integrity. Key among them is lack of access to actionable data to drive meaningful revenue cycle improvements. Greater data transparency is needed to secure data from disparate billing, operations, and compliance systems. Leveraging key performance indicators (KPIs) helps identify current and emerging risks so organizations can explore the root cause and take the necessary corrective action(s). Workforce shortages remain a top concern. The lack of skilled, knowledgeable HI and revenue cycle professionals can lead to billing and compliance errors at a time when organizations can ill afford lost revenue. Through automation, organizations can streamline many front- and backend functions and redirect staff towards revenue integrity solutions. Provider organizations should actively upskill and reskill HI and revenue cycle staff to fill workforce gaps, the panelists suggest. This not only addresses the workforce shortage, it is also an effective recruitment and retention tool. Provider organizations should seek technology solutions that drive revenue cycle optimization. This includes adopting systems that support key functions throughout the revenue cycle, from pre-authorizations to coding accuracy to denials management. Revenue cycle automation creates a seamless experience for clinicians and patients, enabling thorough documentation, coding accuracy, and efficient billing. Return on investment is achieved through improved claims, enhanced revenue capture, and risk avoidance. The Role of HI in Revenue Integrity HI professionals play an integral role in achieving revenue integrity as they process and manage patient data throughout the patient lifecycle (from the point of access to final billing). Specifically, HI professionals ensure patient data is used correctly by auditing coding and billing for accuracy and compliance. HI professionals also support the charge description master (CDM) to maximize reimbursement, ensure compliance with both government and private payers, oversee denials management, and support clinical documentation integrity. The panel recommends HI professionals play a greater role at the point of documentation to reduce note bloat within patient records by eliminating unnecessary information that does not reflect the care provided. The role of HI professionals in revenue integrity will continue to evolve to reflect changing payment and regulatory requirements. We need to leverage our technology and our AI to get clean claims out the door. Kimberly Serry, ChristianaCare It’s important for HI professionals to have a seat at the table to help drive revenue integrity. Their involvement is critical to achieving revenue integrity and sustaining results. Caroline Znaniec Protiviti Continuous process improvement is a key component of revenue integrity. The panel notes several challenges to ensuring complete and accurate coding, including lack of automation ( e.g. computer-assisted coding), disparate electronic health record systems, varying payer rules, and the need for greater clinician education. HI professionals are leveraging data analytics to overcome these challenges. By tracking KPIs, including coding accuracy, number of queries, missed charges, and denials, organizations can identify and focus in on areas of opportunity to address revenue leakage. Benchmarking KPIs also sheds light on where to focus clinician and coder education to address areas of concern. Leveraging Data to Enhance Collaboration Leveraging data analytics is fundamental to revenue integrity. It supports informed decision making to change behaviors across the organization that hamper revenue integrity and provides actional insight to enable sound policies and procedures to correct them. Essentially, data tells the story behind revenue cycle performance that can then be used to educate and exact change. Data bridges the gap between stakeholders and bolsters collaboration by building awareness and holding stakeholders accountable for results. Revenue integrity is becoming a priority as organizations recognize its importance in achieving business objectives. Gina Sanvik AHIMA Conclusion Revenue integrity is fundamental to success in today’s complex healthcare environment. It ensures a unified, systemic approach to revenue cycle optimization, preventing revenue leakage and maintaining compliance. HI professionals play a pivotal role by supporting accurate, timely coding; facilitating clinician education; and efficiently managing patient information throughout the payment lifecycle. Data analytics supports continuous process improvement throughout the revenue cycle and supports collaboration among stakeholders, including clinicians, coding teams, and the business office. By painting a clear picture of operational performance, organizations can gain actionable insights and ensure every patient encounter is accurately converted into revenue in accordance with applicable laws and regulations. Upskilling and reskilling our workforce is a big recruitment and retention tool. Mazette H. Edwards, Northwell Health System Key Findings Revenue integrity identifies and corrects systemic processes and systems that lead to revenue leakage, ensuring provider organizations receive appropriate reimbursement for all services provided. Revenue integrity reconciles critical billing, operations, and compliance functions to generate clean claims and proactively reduce denials. HI professionals play an integral role in achieving revenue integrity, managing patient data from point of access to final billing.
