What is Revenue Integrity, and how can your organization best achieve it? (Sponsored Content)

Monday, March 5, 2018

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By: David Fletcher, MPH, Vice President, Innovations, Streamline Health, Inc.

Ten years ago, not many hospital administrators would list revenue integrity as a major organizational priority, but today the concept is more important than ever. In fact, nearly a quarter of hospital CFOs name revenue integrity as their top priority, according to a recent Healthcare Financial Management Association (HFMA) survey.

But when it comes to implementing new practices and guidelines to address revenue integrity, one must first clarify: what does revenue integrity actually mean? And how does it fit into your organization’s current strategic and operational approach to revenue cycle management?

Creating a revenue integrity definition


David Fletcher, MPH

A hospital that institutionalizes revenue integrity has likely prioritized an approach to coding encounters in a way that maximizes legitimate reimbursement. The key word here is “legitimate”, as in legally and contractually compliant. Revenue integrity for a hospital is more than being morally upright. Being fully compliant in coding and billing practices also reduces the risk of costly downstream efforts such as managing external audits and even payment denials. Revenue integrity brings operational efficiency. The reasons in support of revenue integrity are sound and few would argue against them, yet so many organizations struggle with this. Why is that?

In healthcare, we used to hear the term “revenue optimization”. We don’t hear that so much anymore because it seems to focus only on increasing reimbursement without consideration for legal and contractual compliance. Most organizations have evolved beyond that and are actively prioritizing legal and contractual compliance. This is where revenue optimization becomes revenue integrity. However, the challenge in doing this is that legal and contractual compliance are complex and ever changing goals in the healthcare industry. Reimbursement rules often differ from payer to payer and even patient to patient. For patients in managed care or value-base payment plans, measurement of quality outcomes is critical, while for patients in traditional fee-for-service plans a keen focus on code and modifier combinations is critical. Balancing the drive to increase revenue with the imperative to comply with rules is the essence of revenue integrity. And it also helps illustrate how difficult it can be to achieve this goal in the 24/7/365 “Margin vs Mission” world of healthcare.

So: how do providers go about ensuring revenue integrity in their organization?

People, Process and Technology

The three main elements of a successful business strategy are people, process and technology.  To implement a successful revenue integrity strategy, you must involve stakeholders from relevant departments, reinforced with an organizational commitment to transparency. These departments might include HIM, CDI, Quality Improvement, and Revenue Cycle Management. Siloed departments make transparency difficult, as one team’s change can impact another team’s measurement. Each team’s ability to collaborate with others, or even appreciate their own role in supporting revenue integrity, is often limited. By promoting communication throughout the medical center’s operations, leaders will begin to see how their view of revenue integrity meshes with that of other stakeholders.

In a revenue integrity strategy, the process and technology elements are more interwoven, as software is usually the underlying vehicle that drives processes, and the software is only as effective/productive as the processes it supports. Therefore, a key process change to increase revenue integrity is to commit to assessing and addressing accuracy issues earlier in the cycle. To achieve this, you need technology that can cross-check billing codes and provide actionable analysis before bills are dropped. This enables a proactive revenue integrity strategy, vs. the more common reactive strategy of responding to post-billing feedback that’s generated after the denials or compliance issues have occurred.

Automation to Drive Your Efforts

The answer here is to put the intelligence of experienced auditors into a machine in a highly focused manner. Expert rules and pattern recognition on historical auditor data (AKA, machine learning) represent a quantum leap for a revenue integrity program. Using automated accuracy assessment, all coding can be analyzed prior to billing. Those cases that have questionable code combinations are flagged and routed for review, while those within an acceptable accuracy range can flow through to billing. It’s a more manageable way to screen all encounters, while enabling optimal use of resources on the highest priority cases.

By identifying and addressing the cases with highest likelihood of issues prior to billing, risk exposure is mitigated and compliant revenue capture is optimized. That’s how revenue integrity is achieved, empowered by Streamline Health eValuator™.

To learn more about how eValuator can optimize revenue integrity at your organization, visit StreamlineHealth.net today.

About the author:

As Vice President of Innovations at Streamline Health, Inc., David Fletcher oversees solution management, engineering and lifecycle management for Streamline’s solution portfolio. David acquired his Masters in Public Health in Epidemiology and Health Education from the University of Michigan and began his career tracking and controlling epidemics in New York City. He held multiple positions at Montefiore Medical Center in both their jail health program as well as at the main medical center in the Bronx, NY. The demand for information and analytics to support this work spurred David’s passion and learning for making great software.

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Revenue Integrity

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Sample action plan for implementing a revenue integrity department or function