Revenue integrity: Complexities, collaboration, and commitment

Tuesday, June 8, 2021

by Amy Tepp, CPA

Those of us who have been in healthcare for more than a few years (maybe a few decades) came to know of revenue integrity about 15 years ago. It provided a term to describe the functions organizations had been performing but packaged them with a unique identity within the revenue cycle. The functions of charge capture, clinical documentation and coding, and chargemaster are critical components to ensuring revenue integrity while also maintaining compliance.

The onset of electronic health record (EHR) systems heightened the importance for organizations to have a defined revenue integrity function. We learned that, in some cases, charges were dropping based on flow sheets from the clinical side of the system. In other cases, charges dropped from electronic charge capture screens where the clinician would click on the services and items provided to the patient. Charge routing rules were set up in the background to point the items and services to the revenue department within the system. In addition, these rules would select the charge amount and other relevant items found within the chargemaster (or the components making up what would be a chargemaster) to capture this from an accounting perspective and ultimately to the claim form that is submitted to the payer for payment. The variety in how charges are documented and generated, the interrelatedness of the various components within the system, the interaction of the EHR and the various billing software modules all add to the complexity of revenue within a healthcare organization. This complexity translates into numerous opportunities for potential errors to occur.

It is this complexity that led to the development of the revenue integrity department I managed at a safety net teaching hospital for nearly seven years. At the time, this department had analysts with backgrounds in chargemaster, compliance, pricing, charge capture, revenue side of EHR, and professional and facility coding and billing. Each individual’s skillsets complemented those of others on the team.

As director of reimbursement, revenue integrity, and regulatory review and analysis who reported to the CFO, I was able to connect finance and cost reporting to this group. Linking the chargemaster function to the cost report preparers opened dialogue required to ensure proper matching of revenue and expenses on the cost report. Another benefit of connecting finance to the revenue integrity group was raising awareness of the annual CPT® code changes and how they might impact budgeted revenue.

Our revenue integrity group was also responsible for analyzing and recommending the facility’s annual price changes. Again, this required collaboration with finance on price increases for budget purposes and also called for connecting with payer contracting to facilitate communicating these changes with our contracted payers.

Revenue integrity may look different among organizations, but the importance of the function remains the same: to ensure compliant charges are captured for services provided and revenue is obtained and retained for long term financial stability and success.

About the author

Tepp is a partner, revenue cycle services, at Eide Bailly, LLP.