Health system seeks to define revenue integrity functions

As revenue integrity departments continue to evolve, facilities are often faced with the challenge of determining which tasks must fall to these departments and which are best suited for other revenue cycle roles. With so many department functions overlapping, defining revenue integrity-specific functions is a complex task.

“We’re spending a lot of time now looking at our charge capture billing process and trying to determine what needs to be governed by revenue integrity and what doesn’t,” says Valerie Clark, MBA, CPC, CPCO, director of revenue integrity and compliance and privacy officer for SCL Health’s System Revenue Services Center in Broomfield, Colorado. “We decided to step back and look at our whole charge capture process to determine where the workflow gaps are where revenue integrity principles and concepts can have the most impact.”

SCL currently breaks down its revenue integrity department into two teams. The first team is responsible for managing regulatory-driven edits, including work queues for coding edits and performing laboratory edits. The other is responsible for regulatory audit work, including monitoring Medicare Recovery Auditor activity as well as payer and medical necessity audits. SCL is currently reviewing workflows to draw the line between charge description master (CDM) duties and revenue integrity duties.

In the past, the staff at SCL struggled with identifying CDM errors early on, which would trigger edits. “There’s a disconnect out there. We’re missing the loop back around to the departmental staff and clinicians who perform the services and either choose charges from a pick list or data enter them,” says Clark.

Clark’s goal is to train clinical department staff so that charging is accurate at charge entry, which should help decrease the number of edits triggered. This will help to streamline the accounts receivable payment cycle, says Clark.  

Medically Unlikely Edits (MUE) are common payer edits, which hospitals might use on a claim if a drug is administered to a patient two or more time a day, but the payer standards indicate only one unit of the drug is payable each day. Clark’s goal is to get to the root cause of the edit and train clinicians to understand how payer edits can impact departmental revenue.

“In the case of a drug unit MUE edit, there are many clinical reasons to administer a medication more than once a day, but the payer will only pay for one unit, which impacts cost-to-charge ratios and departmental revenue,” says Clark.

The end goal is to identify where revenue integrity check-points need to be inserted into clinical department workflows so that documented services are entered accurately from the start and are not stopped in any work queues.

“I do think we have to get to a place where clinical staff is at least willing to listen and we can show them with data and actual payer denial information that we’ve got an issue and need to pull a group together to figure out how to correct it,” says Clark. “We can continue to use more and more resources on the back end of the billing cycle or we can loop back to clinical staff and help establish a behavior change that gets us the most accurate charge in the first place.”

Another area of focus for the revenue integrity team is managing and minimizing who has access to the billing system.

“There is a concern created when CDM folks within the finance department set and maintain fee schedules as well as perform charge corrections and adjustments to patient accounts,” says Clark. “It creates compliance and internal audit risk because one person is privy to the entire charge and payment process with the ability to alter entered charges, amounts charged, charge corrections, and payment/adjustment posting.”

The combined ability to manipulate charge codes, send claims, post payments, and delete accounts should only be assessable by a small handful of staff, advises Clark. But where do you draw the line between CDM, HIM coding, and revenue integrity? How do you separate staff who set up and maintain the charge fee schedules from staff who correct, add, remove, and adjust charges or post payments to patient accounts? 

SCL is currently examining charge capture processes with the help of leaders from the internal audit department and other revenue cycle teams, including CDM and HIM. The plan is to take the high-level charge capture and revenue cycle process and determine where regulatory guidance or payer rules impact the processes. The next step is to identify whether current staff assigned to perform the duties are the ones best suited to make the decisions regarding adding and removing charges, determining procedural modifier applicability, or coding accuracy.

In addition to working through the overall charge capture process, SCL is also reaching out to several other facilities to determine how its revenue integrity programs are structured and what work specific revenue integrity teams perform. Specifically, Duke Health in Durham, North Carolina, and Intermountain Healthcare in Salt Lake City are serving as points of reference.  

SCL has reached out to the revenue integrity department at Duke to review organizational structure and workflow and to the internal audit department at Intermountain for organizational structure and contact information for their revenue integrity department. Each organization is noted for its advanced revenue integrity and compliance frameworks.

According to Clark, SCL will continue to query other organizations noted for creating benchmarks and doing innovative work in revenue integrity. When SLC selects a structural model, team members will visit a few of the organizations with such a model so they can see it in action.

“Even though revenue integrity is always on a wave of change, SCL is on a quest to select a structural model to build on, spread revenue integrity knowledge throughout charge capture process, and shift work where it makes sense,” says Clark.

SCL hopes to make changes that lead to less time and resources spent in system edit work queues, reduced work queues altogether, reduced insurance denials, and a reduction in days in accounts receivable.