February 12, 2024

A Comprehensive Approach to Revenue Integrity

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Revenue Integrity is the glue that binds the clinical operations with coding, business office, and financial operations. The goal is to break down traditional silos, embrace challenges, and work collaboratively to achieve success in today’s complex healthcare environment. A comprehensive Revenue Integrity program establishes a holistic approach across the revenue cycle to achieve operational efficiency, complete regulatory compliance, appropriate reimbursement, and patient financial satisfaction.

Functional areas of concentration include:

  1. Charge Description Master (CDM) Integrity
  2. Clinical Services Liaison Team
  3. Charge Review Team
  4. Audit Response & Appeals Review Team
  5. Proactive Audit Program

Let's take a deeper dive into each one of the functional areas of concentration.

Charge Description Master (CDM) Integrity

The CDM is the master table file that contains the basic elements for identifying, coding, and pricing any service or item that may be provided to patients, including procedures, services, and supplies. There are numerous data elements found within the CDM (department numbers, item numbers, item descriptions, prices, general ledger numbers, revenue codes, and HCPS and CPT codes). The CDM is the nucleus of Revenue Cycle and ensuring that it is accurate, complete and used appropriately is vital to ensuring appropriate revenue generation and protection.

Clinical Services Liaison Team

This team is service focused with a project management emphasis. Clinical Services Liaisons focus on improving revenue results by taking a global view of clinical and financial processes, functions, and interdependencies from the provision of patient care to final bill generation. They are seen as key partners establishing the bridge between operations, finance, and I.T. for existing business, new service line creation, and potential future acquisitions. The team provides guidance and education on correct and complete charge capture, coding, and billing processes to clinical departments and practices. Finally, they monitor government and commercial payers for updated and changes to billing requirements. They will communicate and educate clinical and administrative staff on actions required to comply with new regulations.

Charge Review

Charge Review Analysts review accounts flagged for potential missing charges. They interact with clinical departments to obtain additional information needed to properly bill accounts based on clinical documentation. Most of their day involves reviewing, analyzing and resolving accounts that have failed coding and charging related claim edits, including medical necessity, National Correct Coding Initiative (NCCI), Medicare Outpatient Code Editor (OCE), Medically Unnecessary Edits (MUE), and other exceptions requiring clinical/coding expertise. The team also assesses the accuracy of all charging vehicles, including clinical systems and dictionaries, encounter forms and other charge documents. Finally, Charge Review Analysts execute on charge reconciliation protocols to ensure revenue protection and minimize late charges, working closely with all clinical departments and with the Central Business Office.

Audit Response & Appeals Review

This team manages, tracks, and responds to all government and third party payer audit activity, including RAC, MAC, MIC and other third party payer audits. They ensure accurate tracking, research, and timely completion and resolution of clinical appeals. They also conduct review of chart documentation, regulatory and payer guidelines to analyze and formulate appropriate responses and / or appeals. Finally, this team updates policies and procedures to document any redesigns of workflow and / or policy.

Proactive Audit Program

A proactive audit program ensures that revenue protection is achieved by reducing the risk of recoupment and punitive fines in the event of a government or third-party audit. A best practice approach will provide detailed and focused audits at regular intervals that encompass all facilities and service lines to ensure appropriate charge capture and regulatory compliance.

Why is revenue integrity important? In today's complex and dynamic healthcare environment, it is essential to both grow and protect revenue. Major benefits of a comprehensive revenue integrity program include improving accurate revenue generation by focusing on charge capture and coding, and increasing revenue retention by focusing on proactive auditing and compliance. Industry estimates show that implementing a comprehensive revenue integrity program can yield a 0.5% o 2% increase in net revenue.

Contact Revigate today for assistance with your revenue integrity strategy.

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