The role of revenue integrity in organizational compliance

Revenue integrity professionals plays a key role in compliance within the organization by virtue of their role in the design and maintenance of the chargemaster. These staff work to ensure that the chargemaster can live up to an audit by any payer at any time. Additionally, revenue integrity staff members are frequently involved in the analysis and quantification of any billing error, question, or concern. These staff will run reports and analyze data to determine the extent of the billing problem and payment implications. They also work with the information technology and information security staff to design edits and flags in the electronic medical record system to prevent the occurrence of the same or similar billing error in the future. The revenue integrity professional supports the following seven elements of a successful compliance program and is an integral piece of the compliance program design and effectiveness:

1. Standards of conduct/policies and procedures. Revenue integrity professionals work to design a variety of policies and procedures. These staff, along with others in the organization, are held to the standards of the code of conduct adopted by the organization’s board of directors.
2. Compliance officer and compliance committee. Revenue integrity professionals provide valuable insight and information to the compliance officer and staff for reporting on claim accuracy and audits to the compliance committee.
3. Education. Revenue integrity professionals assist in education of diagnosis and procedure code-specific documentation requirements to ensure the submission of clean claims to the payers.
4. Monitoring and auditing. Revenue integrity professionals assist in the auditing and monitoring of items as designed in the annual compliance work plans.
5. Reporting and investigating. Revenue integrity professionals may encounter and report items of compliance concern and assist the compliance department with the investigation of the issue to facilitate timely and appropriate remediation.
6. Enforcement and discipline. Revenue integrity professionals are subject to the same requirements for enforcement and discipline as the rest of the organization’s workforce. Their expertise is valued in terms of looking at the compliance issue and how best to address specific disciplinary actions, given the nature of the infraction.
7. Response and prevention. Revenue integrity professionals may be called upon to assist in the response and prevention of compliance issues given their broad knowledge of the revenue cycle and expertise in billing and payment collections.

The role of the revenue integrity professional is vast and varied and deeply embedded in the success of the revenue cycle. It is these staff members who contribute to the success of the compliance and privacy programs at each organization. The collaboration of revenue integrity, revenue cycle, privacy, and compliance results in oversight of the documentation, billing, collection, and integrity of the medical record. This helps ensure that the organization can successfully respond to all audit requests without sanctions or fines.

In the complex world of healthcare, it is not a matter of if an organization will receive an audit request but when the audit request will arrive. Knowledgeable, educated revenue integrity professionals who collaborate with their colleagues in compliance and the revenue cycle will be on the forefront to assist their organization in the challenges these audits present.

Editor’s note: This article was excerpted from Core Functions of Revenue Integrity, Second Edition.