HIM, and case management. Representatives
from Radiology, Respiratory Therapy, Surgery,
Endoscopy, Nursing, Lab, Pharmacy, Cardiac
Cath, Wound Healing, the Emergency
Department, Physician Practices, and
Rehabilitation department should be appointed
as ad hoc members that attend meetings,
Revenue integrity functions
Whether revenue integrity functions are integral to a formal team or department or part of
impromptu process improvement efforts, the
gains realized from the following performance
improvement activities will go a long way in
solidifying the revenue cycle.
Effective revenue integrity analysis should
begin with mapping/charting revenue cycle
workflow. This function is necessary to identify
procedures, responsibilities, redundancies, and
bottlenecks. Often, the actual current state does
not match the perception of how processes occur.
Monitor unbilled days and aging accounts
receivables (AR) closely. Exceedingly high
unbilled days and aging accounts are the first
clues that revenue integrity is compromised.
Examine AR regularly to identify issues and
trends, and implement solutions quickly to
improve days in AR and increase revenue.
· Ensure the team members in the appropriate
areas (e.g., HIM/Coding, Billing/Finance)
are correctly monitoring productivity
· Establish a policy to ensure timely charge
capture and prevent excessive late charges.
· Track and trend the number of claims
(including total charges) that encounter
internal edits that prevent prompt billing.
· Perform root cause analysis of the issue and
collaborate with affected areas to determine
an appropriate solution.
· Communicate trends and total charges by
location to core team and appropriate ad hoc
team members, and implement process
improvements to ensure that problems are
resolved and do not unnecessarily recur.
· Consolidate denials management and
· Identify root causes (e.g., competencies,
education needs, system issues) and collaborate with appropriate areas to minimize
recurrence or increased denials.
· Communicate top denials with all team
members and provide training accordingly.
· Develop innovative policies and procedures that cultivate proactive resolutions
at the point of care, and minimize manual
revenue cycle interventions as much
Maintaining revenue integrity
Achieve and maintain revenue integrity with a
solid internal audit plan that includes regular
review of clinical documentation to ensure
that the level of care, charges, and codes
assigned are supported. Results should be
communicated with the appropriate revenue
integrity team members to determine education and improvement plans.
The integrity of the data your healthcare
organization is using now — in 2017 — will
determine the payments you receive and the
penalties you incur in 2019. Thus, for your
organization to survive in the value-based
environment, you will be wise to establish a
process for validating the data. Revenue integrity must be a formal, centralized process that
is ongoing and inclusive of all departments
and individuals that affect the revenue cycle.
In addition to supporting your claims, engaging in the effective management of revenue
integrity will decrease days in AR and provide
an accurate depiction of performance, cost,
resource utilization, and quality of care, which
will assist with the transition from volume