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What is revenue integrity, and why is everyone in healthcare talking about it?

No matter what industry you’re in, revenue integrity seems to be a constant buzzword. In healthcare, however, it is more than just a buzzword — it’s a way of doing business and of separating organizations that grow and thrive from those that merely survive.

So what is revenue integrity anyway, and why is everyone talking about it?

It’s a term that can mean many different things to different people. But almost across the board, for most organizations, revenue integrity means using ethical business practices and policies to achieve three critical organizational imperatives: operational efficiency, compliance, and optimal earned reimbursement/payment. An organization should keep all three at the top of its priority list, and all three should work in tandem.

In a 2017 HFMA Magazine article, “The Future of the Revenue Cycle,” Suzanne Lestina, HFMA revenue cycle technical director, defined revenue integrity as “the right delivery, the right protocols to ensure right (accurate) reimbursement and compliance.” According to the HFMA article, the goal of a revenue integrity program is to prevent the recurrence of issues that can cause revenue leakage, revenue degradation, and compliance risk.

A healthcare facility that wants its operations to be centered around revenue integrity should create a specific set of guidelines and procedures that all leaders and employees, especially those who manage the organization’s revenue cycle, must follow. Some examples might include coding services in a way that provides for and optimizes legitimate reimbursement.

If you’re compliant in your coding and billing practices, you’ll reduce your risk of external audits and possibly even payment denials, saving time and money for the entire organization.

A good revenue integrity program also will catch underpayments and overpayments. In a November 2019 audit, the Office of Inspector General (OIG) found that Medicare overpaid acute-care hospitals $54.4 million for 18,647 claims subject to the Post-Acute-Care Transfer (PACT) policy for services provided between January 1, 2016, through December 31, 2018. PACT was enacted in 1998 to prevent CMS from overpaying for a patient’s care. The audit recommended that CMS direct MACs to recover all overpayments where the discharge status is incorrect due to the patient receiving post-acute care.

According to a 2017 HFMA/Navigant Consulting survey, revenue integrity is critical to ensuring that revenue is accurate in coding and charge capture, that it is reasonable for services provided, and that it complies with laws and regulations.

If your organization isn’t taking revenue integrity seriously yet, it definitely should be. In the same HFMA/Navigant survey of 125 hospitals and health system CFOs and revenue executives, nearly one-quarter (22%) cited revenue integrity as a top priority. But only 44% said their organizations have established programs. According to the survey, those that have implemented a program have seen eye-opening results:

  • 68% increase in net collection
  • 61% overall gross revenue capture
  • 61% reduction in compliance risk

Without an established revenue integrity program in place, it is highly likely that your revenue cycle isn’t performing as effectively as it could be.

According to Jake Morris, managing director at Navigant: “Revenue integrity should be the glue that binds clinical operations with coding and business office functions. It’s clear that providers with established RI programs are benefiting from them, and expanding their scope will help yield long-term financial reporting reliability and operational efficiencies.”

Another way to look at it is by thinking of your revenue cycle as the vehicle that drives your entire organization. Revenue integrity should be the steering wheel as well as the windshield you look through to drive.

Achieving Revenue Integrity

You may know what revenue integrity is and why it’s important, but the trick for most organizations is how do you achieve it?

First, a successful program requires the buy-in of stakeholders from every part of the organization. Transparency and communication are key to any revenue integrity program. Healthcare organizations need to get reimbursed properly for all services and care provided. Revenue integrity requires them to comply with legal and contractual policies to help ensure that they do so.

Revenue integrity also calls for balancing the desire to increase revenue with the need/responsibility to comply with rules. Keeping up with legal and contractual compliance, which is ever-changing and, therefore, very complex by nature, is not easy and requires every employee’s support.

Practical reasons to champion revenue integrity in your organization include:

  • Recovering revenue
  • Identifying incorrect and under-coded claims, as well as missing charges
  • Ensuring DRG anomalies are found and properly reviewed
  • Reducing the risk of external audits
  • Decreasing payment denials
  • Supporting HCI by driving revenue

All of these save time and money for the entire organization. How do you get there? The goal is achieving operational efficiency, compliance, and optimal earned reimbursement through ethical business practices and policies. According to HFMA, revenue integrity can only be achieved with the proper processes, tools, and related expertise.

Technology can help meet revenue integrity goals

Technology can play a vital role in helping organizations maintain processes that align with their revenue integrity goals. For example, automated RCM solutions can free up staff so that they can focus more time on patients. Automatic scanning can enable staff to analyze coding before submitting claims to reduce denials.

Comprehensive, automated Medicare reporting and analytics provide greater insight into your billing process so you can spot any issues that may negatively impact your Medicare claims and follow-up efforts. Also, checking eligibility in real-time straight from the Medicare system can help you solve reimbursement issues before they start.

With the right tools, you can even clean up your organization’s finances and, therefore, boost your revenue integrity. If your hospital has a collection of transfer DRG-related underpayments, your revenue cycle is likely not operating efficiently and you’re losing revenue that’s rightfully yours.

With our Transfer DRG tool, Waystar’s proprietary intelligent technology employs an automated end-to-end process to identify TDRG underpayments (with a four-year lookback period) and then adjust those claims on your behalf in Medicare’s system. The average recovery for our clients is $3,500 per underpaid claim. We always find additional underpayments regardless of whether it’s performing a first-time review, a secondary, or even tertiary review. We also can find more underpayments faster than other solutions thanks to the unbeatable combination of our intelligent technology and access to Medicare data. Because our product relies on Medicare data, we can spot overpayment trends, too. So we can help prevent your hospital from being audited.

Don’t take shortcuts to revenue integrity. If you’re among the more than half of healthcare organizations that haven’t yet implemented a revenue integrity program, start now. The sooner you begin your program, the sooner your revenue cycle can start performing at its highest level. Find out more about how you can stop leaving revenue on the table with Waystar’s Revenue Capture suite.

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