South Shore Health System created a formal revenue integrity department to focus on due diligence during its EHR transition.

When Massachusetts-based South Shore Health System began its journey toward a new electronic health record (EHR), executives wanted to ensure a smooth transition—a goal that required a proactive approach to safeguard revenue, says Bettyann Carroll, executive director of the health system’s revenue cycle.

South Shore Health System is a not-for-profit, tax-exempt, charitable health system that provides acute care, ambulatory care, and home health services to the 700,000 residents of southeastern Massachusetts. It is the parent organization of South Shore Hospital, South Shore Medical Center, South Shore Visiting Nurse Association, Hospice of the South Shore, South Shore NeuroSpine, and other not-for-profit health organizations.

Carroll was hired at the onset of the EHR transition to create a formal program that would mitigate revenue loss in the short- and long-term, ensuring the health system’s financial viability in an increasingly competitive healthcare marketplace.

Revenue integrity is always important, but it’s particularly critical during times of IT transitions when organizations are financially vulnerable, says Carroll. When clinicians simply layer new technologies over existing inefficient charge-capture processes, revenue loss can occur. Organizations that identify—and address—these and other vulnerabilities before, during, and after a major transition, such as an EHR conversion, end up reaping a greater return on investment in the long-run, she adds.

Three Pillars of Revenue Integrity

To be successful, revenue integrity requires the following three prongs:

  • Documentation and coding accuracy
  • Accurate and timely charge capture
  • Denial and risk mitigation

In some organizations, each of these prongs is delegated to already-existing departments such as health information management, finance, or clinical documentation improvement. South Shore Health System created a formal revenue integrity department because it wanted to focus on due diligence during the EHR transition. Leaving money on the table was not an option. It also wanted to provide support for clinicians, many of whom play a critical role in ensuring accurate payment.

“We wanted dedicated staff resources who could partner with the clinical folks,” says Carroll. “We’re the liaisons between clinicians and finance.”

When it comes to revenue integrity, clinician engagement is paramount. “Revenue integrity is about building relationships,” says Carroll. “You can’t work in a silo. You really need to have that integration.”

Creating Revenue Integrity Structure and Goals

South Shore Health System’s revenue integrity team is tasked with building this integration. The team consists of the following members.

Director. Provides revenue integrity oversight and leadership.

Revenue recovery analyst. Conducts root-cause analyses of denials to drive operational process improvement and redesign.

Charge capture analyst. Helps clinical departments interpret revenue and usage reports, provides clinician education to ensure accurate charge capture, and facilitates necessary updates to the charge description master (CDM).

Revenue integrity analyst. Manages payer pre-bill edits and educates outpatient clinic providers and their staff regarding proper documentation, code selection, and modifier assignment.

In preparation for the health system’s EHR go-live date, the team focused on the following actions.

Gathering department-specific charge capture baselines (e.g., types and volumes of charges, revenue generation, and posting lag-time). This includes the daily, monthly, and annual volumes of lab tests (e.g., complete blood counts or renal panels) and radiology tests (e.g., CT scans, X-rays, or MRIs) to determine whether the department was reaching or exceeding charge capture baselines at the go-live date and to ensure that charges were not omitted.

Meeting with clinical departments and information systems to design optimal charge capture models. This includes charges based on provider encounter note documentation, lab or radiology results, or nursing administration of medications.

Preparing clinical departments for training, testing, and go-live readiness. All staff members received application-specific end-user training. They also attended special workshops to learn more about major changes in processes or workflows (e.g., denials management, charge capture, or charge reconciliation).

Eliminating charge backlogs and challenges in legacy systems. In some cases, the hospital used per diem and temporary staff members to clean up as much of the work as possible prior to the go-live date.

Carroll provides these examples of how revenue integrity team members have provided important oversight during the EHR transition.

Develop user-friendly evaluation and management (E/M) templates in the EHR. The revenue integrity team serves as the liaison between clinicians and IT and works with IT professionals to develop tools within the EHR that accurately and seamlessly translate physician documentation to E/M levels.

Identify processes for daily charge reconciliation. The revenue integrity team helps clinical departments identify a primary and backup point person who is responsible for charge reconciliation as well as addressing any charge errors that occur (e.g., late or missing charges, inaccurate charge levels, or missing bedside procedure charges). It also develops best practice polices for charge creation and reconciliation.

See related tool: Charge Description Master Policy and Procedures

“We ensure all departments get adequate training and practice prior to go-live so individuals have the skills and confidence to own the charge capture process,” says Carroll.

Coordinate CDM updates. The revenue integrity team collaborates with the following individuals as questions arise or as new departments, programs, or services are implemented to ensure that the CDM includes accurate and updated information:

  • Clinicians—to identify the specific services that are rendered to patients.
  • Medical coders—to identify the CPT and HCPCS codes that accurately depict these services.
  • Finance representatives—to identify the appropriate CDM codes and associated charges.

Carroll says working collaboratively ensures that the health system accounts for all revenue sources, and it also helps clinical departments better understand their own charges.

Identify opportunities for charge capture automation. The revenue integrity team works with each clinical department to identify the most efficient and effective charge capture methodology. For example, respiratory therapy charges are automatically generated from flow sheets (i.e., documentation of a therapist’s treatment, including the date, duration, and supplies used). Similarly, medication charges automatically occur when nurses administer drugs.

“This is great because we don’t charge inappropriately,” she says. “If the patient never got the medication, they shouldn’t be charged for it.”

The revenue integrity team not only helps identify opportunities for charge automation, but it’s also closely involved with any testing necessary to ensure accuracy prior to go-live.

Revenue Integrity Beyond IT Transitions

South Shore Health System’s revenue integrity efforts certainly won’t end when it goes live with its new EHR in July 2017. In fact, during the go-live phase, the team will continue its work with the following activities:

  • Monitor the timeliness and accuracy of charge capture and reconciliation.
  • Provide rapid response solutions to address gaps and variances.
  • Round to clinical departments to ensure revenue stabilization and workflow clarity.

Post-go-live, the team will do the following:

  • Continue to monitor charges.
  • Identify and communicate lessons learned.
  • Track metrics and drive process improvement to meet revenue targets.
  • Create optimal charge solutions for new services lines and/or providers.

South Shore Health System’s revenue integrity team has also begun to look beyond the EHR implementation to focus on revenue capture during other transitions, such as the addition of new service lines. For example, Carroll says the team has been instrumental in providing operational guidance as well as charge capture education for clinicians involved in its new bariatric surgery program. More specifically, the team has been involved in the following activities:

  • Partnered with clinicians to identify specific bariatric surgery procedures performed.
  • Contacted payers to determine medical necessity requirements for these procedures and created a payer matrix for easy reference of these requirements.
  • Educated patient access representatives on when to obtain prior authorization.
  • Provided coder education to ensure accurate and compliant coding of bariatric procedures.
  • Created templates in the EHR to ensure that clinicians document information necessary for coding.
  • Worked with finance to add any new and relevant charges in the CDM.

Measuring ROI

Carroll says the health system’s revenue integrity program is still too new to be able to quantify a specific ROI. However, clinicians have responded favorably. Not only does the revenue integrity team provide ongoing clinician education, but it also invites one clinical department per month to attend a meeting where clinicians talk about their charging and billing challenges—and the revenue integrity team helps identify solutions.

“It’s a collaboration and partnership,” says Carroll. “The creation of the revenue integrity department enabled me to create that feedback loop and inform clinicians how they were performing and how their department is doing. They’re grateful for that.”

Lisa A. Eramo is a freelance writer based in Rhode Island.

Interviewed for this article:

Bettyann Carroll, MS, RHIA, is executive director of revenue cycle, South Shore Health System, South Weymouth, Mass., and a member of HFMA’s Massachusetts-Rhode Island Chapter.

Publication Date: Monday, May 15, 2017