How Duke Health structures a dynamic revenue integrity department
The Duke University Health System in Durham, North Carolina, has more than 1,200 inpatient beds, handles two million outpatient visits annually, and serves as one of the country’s leading research institutions.
As the director of revenue and documentation integrity at Duke Health, Garland Goins, MBA is tasked with structuring its complex revenue integrity department.
When Goins arrived at Duke Health in 2014, the initial challenge was to preserve revenue through streamlining processes.
“Like any institution, you have subject matter experts focused on their swim lane(s) and unfortunately or unknowingly creates silos with many conflicting priorities,” says Goins.
To diminish these silos, Goins has formed what he calls IMPACT teams, consisting of revenue managers (a uniquely skilled associate with project management, reimbursement methodology, and charge capture prowess) at the forefront, with a revenue integrity analyst, coding analyst, research analyst, and charge description master (CDM) analyst in supporting roles for each service line within Duke Health. The IMPACT teams are distinct from the four teams within Goins’ department, which includes clinical trials billing, coding integrity, revenue integrity-CDM, and charge integrity. Each of these teams serves a vitally unique role.
Let’s take a closer look at each departmental team.
Clinical trials billing team
The clinical trials billing team is comprised of a clinical trials billing manager, as well as 12 full-time equivalents ranging from four IT analysts, six clinical trials specialists, one revenue integrity analyst, and one reimbursement specialist.
Duke Health uses Epic for its electronic medical record, and Forte’s OnCore as its clinical research management system. The IT analysts work collaboratively with the research community to understand the nuances of how to compliantly construct research calendars/grids based upon a research study’s protocol/profile, Goins says.
Duke Health is a leader in new-to-market therapies, including cellular and gene therapies related to certain lymphomas, cancers, and unique genetic disorders, so Goins’ team must have a thorough understanding of the research studies performed at the health system. There is also the challenge of the Trump administration’s expedited FDAapproval process for new drugs and devices. What was once a 15-year process is now a 7‒10-year process, which means new drugs and new devices are hitting the market sooner.
“But what does the efficacy of this mean or look like and how does that translate into a billable or reimbursable experience for our patients?” Goins says.
Every Monday, Duke Health evaluates possible patients for these new-to-market therapies. Goins has made it a priority to establish a greater relationship with clinical departments driving these therapies. He says it has been instrumental to have individuals on the clinical trials billing team that possess knowledge surrounding both the clinical and billing components.
Coding integrity team
While the coding integrity team is the smallest of the four units, with one coding integrity manager and 10 compliance specialists, the associates wield significant impact on auditing and educating on systematic professional and technical coding risk. Within this department, the compliance specialists bring a variety of professional and technical specialties to the table, including risk adjustment (hierarchical condition categories/risk adjustment factors), interventional radiology, integrated (facility and professional) emergency department and surgical/procedural coding.
The unit is also home to the Medical Coder 1 trainee team, a rigorous two-year program that serves two purposes:
- Allowing professionals with a CPC-A certification to gain experience and remove the “apprenticeship” from their credentials
- Providing Duke Health with a built-in pipeline to groom and place future hires into niche service areas
“By creating this trainee program, we have committed to reinvesting in those individuals dedicated to Duke Health, and with a consistent quality network of individuals to select from, we have seen and will continue to see an increase in proactive recruiting and hiring for these roles,” Goins says.
Goins pointed out that Duke Health requires coders to live in the region, whereas other health systems can hire remote coders. While cost conscience, the program, which is still in its infancy, creates a network of dedicated, placed, and retained hires.
Revenue integrity and charge description master team
The revenue integrity and CDM team is led by two managers—a revenue integrity manager and a CDM manager. It’s the biggest of the four groups, as there are 19 employees—16 full-time—working under the two managers. Job descriptions in this unit include revenue integrity analyst, reimbursement specialist, patient account analyst, compliance specialist, medical coder, and CDM analyst.
Currently, Duke Health has six CDM analysts working under a CDM manager.
The unit performs CDM analysis to maintain a 110,000-to-120,000 line item chargemaster, according to Goins.
“This team collaboratively oversees the economic engine of the health system,” Goins says. “Intricately detailing every supply, drug, and procedure code. They are responsible for the maintenance and compliant adherence of triggering the charges captured in a clinical or professional setting or a hospital or facility setting. It’s a very dynamic group which compliments revenue integrity’s external medical audit request responsibilities well to perpetually ensure Duke Health revenue preservation.”
Charge integrity team
The charge integrity team is unique to Duke Health, but other organizations may have similar teams in place under a different name, Goins says.
The team is comprised of 13 revenue managers and two patient account analysts. Most of the revenue managers align with specific service lines, including cardiology, oncology/cancer, neurology/psychiatry, emergency services, labs/pathology, and radiology/imaging services.
These employees possess sound revenue cycle experience, and they know how to engage colleagues from patient access, charge capture, coding, and patient financial services to have a positive impact on their assigned service line(s). Additionally, they are adept at organizing and structuring large projects over a long period of time.
“They are, I would say, our most forward-facing individuals, simply because they are lock-step with the operational and clinical leaders on strategic initiatives,” Goins says. “How do I plan for the future to sustain my business, in conjunction with how well am I performing? What are my service and procedural revenues, usage and degree of effectiveness? Am I fully optimized and where am I finding denials throughout my processes? How do I avoid any unnecessary write-offs, and truly get to the root cause of how to streamline my operations? These are a just a few of the many questions Duke Health’s revenue integrity IMPACT teams combine and strive to answer on a daily basis.”
Ultimately, the members of this team help service line administrators make informed decisions based on external forces from CMS, managed care payers, and patients on how the necessity and quality of services are going to reimburse, says Goins.