Q&A: Defining revenue integrity functions

Tuesday, June 7, 2022

Q: What are some functions that revenue integrity should be more involved in?

Frank Cantrell, CHRI, corporate director of revenue integrity at Penn Highlands Healthcare in DuBois, Pennsylvania: For managed care and payer contract management, I think [revenue integrity involvement] is key. In our organization, we have a managed care director that handles the contract and language. He relies very heavily on my team if he’s negotiating new contracts or renewing contracts because that is the prime opportunity to get some language in your contracts about the number of days you have to appeal, exactly what your process is for reviewing problem claims, and even just areas where payers are being egregious with some of their rules and policies. While you may not actually do the contracting, I think you have to be a part of that process because you gain so much more from that process if the people who are actually looking at the denials and charging problems [can resolve them]. The other one is chart auditing. We do proactive department auditing. My philosophy has always been, the further upstream we can correct the issues, the fewer billing issues and denials we have. So auditing those outpatient departments specifically for charging compliance and documentation compliance is a huge part of streaming your backend revenue cycle to make sure the charges are correct and meet [medical] necessity before they ever get to the point of billing and potentially being denied.

Priscilla Frost, AGS, CPC, CEMC, CPMA, PCS, PESC, compliance auditor/revenue coordinator at North Caddo Medical Center in Vivian, Louisiana: Not only is it beneficial [to work with payer contracting], there’s many times when you’re working on a contract that the timely filing is something not everybody looks at. You can negotiate it. I think it’s important that everyone who can review those contracts gives that feedback. You have to go to the areas that deal with the daily stuff to understand what needs to be in that contract. And a lot of places don’t.

Editor’s note: This article was excerpted from the 2022 State of the Revenue Integrity Industry Survey Report. Read the full report here.