Importance of Revenue Integrity Programs in Healthcare

The success of any health system’s medical reimbursement is connected directly to the maturity of its revenue integrity practices. For most health systems, their primary source of reimbursement comes from government and commercial insurance payers; therefore, it is wise to focus on these lines of business in which the emphasis should be on timely and accurate claims that capture the clinical efforts they represent.

Many health systems across the US have needed to adapt to an environment with continued erosion of their margin driven by lower reimbursement rates and higher costs. Unlike traditional healthcare delivery, academic medical centers (AMCs) provide comprehensive patient care and fund extensive research and educational programs to contribute to their disciplines as well as train future healthcare providers; therefore, they often operate on very thin margins dependent on sufficient reimbursement for the care they provide. To ensure that they receive the appropriate payment for their services, AMCs must invest in people and procedures who can harness the expertise of every team member to succeed in yielding the triple aim—better care for individuals, better health for populations, and lower overall cost.

The activities of a revenue integrity program can be grouped into three main pillars: optimizing revenue capture, minimizing revenue loss, and reducing the cost of operation. Often, the value of a strong revenue integrity program is understated, but it is the foundation for any strong revenue cycle.

The best way to optimize revenue capture is to bring together leaders from various departments to review with a combination of clinical expertise and understanding of billing operations to ensure that every opportunity to capture revenue is understood and tracked. This review should start with encounter creation (or scheduling) and include how each member of the care team is involved in the visit. The key is to clearly define what ‘completes’ the visits, including documentation, coordination of care steps, charging, and patient communication. It can be helpful to use a RACI diagram to organize this information. Through this process, you are also documenting the data structures to define reports needed to monitor this volume and identify opportunities to streamlineyour workflows.

The main sources of revenue loss are payer denials for lack of coverage or prior authorization and failure to capture new patient demand in a timely manner. 

Requesting and securing prior authorization for a visit should be as standard a step in the process as scheduling the visit. It is important to explain these requirements to the patient and keep them apprised of any updates, then hold yourselves accountable for submitting requests and updates to the payer in a timely manner. While the reimbursement of a single visit is important, it is critical to expand your scope to think about the entire patient's care journey and treat their preventive care gaps, specialty referrals, diagnostic needs, and follow-up care with the same level of urgency to individual account authorization or claim adjudication. Caring for the entire patient journey will not only better serve your community but also strengthen your bottom line.

If not careful, this highly complex environment can lead to escalating operational costs; therefore, every effort must be taken to reduce the administrative bloat naturally brought on by the maturation of health system processes. This can be done by evaluating automation in every step of the workflow, ranging from providing self-service tools to patients, automating authorization requests, triggering revenue directly from clinical documentation, automating coding,and implementing autonomous denial actioning.

At the University of Miami, we leverage our electronic medical record system (Epic) to support all three aims of a successful revenue integrity program. Epic provides a naturally integrated platform to understand and manage the full lifecycle of patient claims. This level of integration is a crucial aspect that ensures healthcare organizations can receive full and legitimate reimbursement for services provided while remaining compliant with all applicable laws and regulations. Strong revenue integrity involves developing and implementing efficient and effective scalable processes and internal controls at every step of the patient journey. Healthcare organizations should develop and maintain a revenue integrity program that evolves in step with the evolution of healthcare.