Q&A: Identifying opportunities for revenue integrity

Q: What are some areas of opportunity for revenue integrity?
Tracy Cahoon, MBA, CHRI, director of revenue integrity at Southwest General Health Center in Middleburg Heights, Ohio: I think managed care is an area of opportunity. I think when you’re doing chargemaster maintenance, pricing strategy, and chargemaster strategy in general, being looped in with the managed care team to understand what your contracts are saying vs. how you are building things on the chargemaster is important. I think that there’s a risk if you don’t understand what your contracts are saying and what’s being expected from a contracting point. Also, recently I’ve gotten more involved with our financial counselling and team that does the patient estimates. I think this is another area where there’s an opportunity to make sure the team understands what should be incorporated into a quote for a patient estimate and [to make sure] they’re using the right kind of logic to put together that patient estimate. We’ve found some areas where we were misquoting because of some wrong billing/charging assumptions when looking at an individual CPT/ HCPCS code vs. quoting for the encounter level. So getting involved from that standpoint has been helpful and we’re becoming a little more accurate how we’re putting those quotes together now.
Andrew Reiten, managed care coordinator at Trinity Health in Minot, North Dakota: Insurance verification is [an opportunity]. To me the easiest way to make money is to take a three or four month old self-pay account and find some insurance to add on to it. [There are] patients that are not responding to letters, they’re not letting us know if they have insurance, but you can see they had a different visit where they had insurance or the eligibility systems will return an insurance. [With changes to Medicaid eligibility related to the end of the public health emergency], I think it’s going to be rough in that we’re going to have patients that we think have coverage, but then the eligibility systems are going to be retroactively updated and they’re going to be self-pay.

Editor’s note: This article was excerpted from the 2023 State of the Revenue Integrity Industry Survey Report. Read the full report here.