Revenue integrity requires a mindset shift from production to an emphasis on quality.
When healthcare organizations prioritize revenue integrity—accurate payments based on compliant practices—they not only reduce external audits and denials, but also save time and money that can be reinvested into patient care. With revenue integrity, it’s all about correct payments. Hospitals increase their net profit by submitting claims correctly the first time, avoiding costly audits, recoupments, and denials.
As hospitals and health systems continue to purchase physician practices, revenue integrity concepts must extend into these settings. This supports long-term financial viability and sustainability during a time when physicians are subject to more audits and payer scrutiny than ever before. Darlene Helmer, director of revenue cycle at the University of Maryland St. Joseph Medical Center in Towson, Maryland, explains how she helped launch a successful revenue integrity program for 130 employed physicians.
How is revenue integrity organized in hospital-owned physician practices? Does someone—or a team—of individuals typically oversee revenue integrity in these settings?
Helmer: I was hired as the director of revenue cycle three years ago. Our medical group of 130 physicians relies on me to lead all revenue integrity efforts in conjunction with a team of other individuals. Do I think that most health systems have someone or a team of individuals devoted to revenue integrity? No. However, I think we’ll see a movement toward a team-based approach or someone specifically overseeing this effort as a best practice of doing business—especially during times of cost containment and value-based payments.
Why haven’t we seen more focus on revenue integrity in system-owned practices thus far? What are the barriers?
Helmer: Staffing and cost are two big barriers. If you hire someone specifically as a director of revenue integrity, that’s an additional cost to the organization. If you take a team approach, it may be easier to absorb the costs, but you’re also adding tasks (e.g., audits, education, and IT updates) to the to-do list for staff members who are already very busy.
Another barrier is that it’s often difficult to get employed physicians to buy into revenue integrity efforts because they’re salaried. We’ve had to revamp our entire bonus structure because of this, moving from a production-based bonus to a quality-based bonus. Physicians receive a bonus only when they meet certain quality metrics related to patient satisfaction, audit scores, and MIPS measures. Another barrier is that some organizations don’t fully understand the benefits of a revenue integrity program; thus, they don’t make it a priority.
What are the benefits of a revenue integrity program?
Helmer: Having a revenue integrity program ensures there’s a formal process in place to perform ongoing audits and educate physicians and their staff about compliance. Revenue integrity is about identifying instances of undercoding as well as overcoding. It’s about accurate coding. Revenue integrity helps protect revenue so practices can continue to provide high-quality patient care.
Revenue integrity can help increase revenue because there are so many safeguards in place such as ongoing auditing and education of providers and staff as well as documented policies and procedures that are enforced. I was previously a corporate compliance officer for an anesthesia practice. When we implemented a compliance program focused on revenue integrity, we literally tripled our revenue in four years—all without adding staff or providers.
With whom do you work most closely to ensure physician practice revenue integrity in your organization?
Helmer: At our organization, we take a team approach to physician revenue integrity. As the director of revenue cycle, I work closely with the director of compliance for the hospital who also oversees compliance for the medical group. We’re considering hiring someone specifically to serve as director of compliance for the medical group. If this individual is hired, I’ll work closely with that individual to maintain revenue integrity in our practices. I also collaborate with our coding auditor/educator, the executive director of the medical group, our onboarding and credentialing team, billing and coding staff, and the director of operations for primary care and specialty care.
Should the size of an organization affect its approach to revenue integrity?
Helmer: Possibly. Smaller organizations with fewer owned practices may not be able to afford an individual to oversee revenue integrity specifically. Instead, they often hire a director of revenue cycle who integrates revenue integrity into all facets of the revenue cycle (e.g., charge capture, data entry, coding, accounts receivable follow up, auditing). Organizations with large practice networks may require dedicated revenue integrity directors because of claims volume and the number of physicians who require ongoing auditing and education.
What role do you think technology and automation play in revenue integrity?
Helmer: Both play a big role. I work with IT every day to make sure our EHR [electronic health record] includes all relevant rules and regulations. For example, our coders see accurate and updated edits when assigning codes, and our front-office staff see automated reminders to obtain an Advanced Beneficiary Notice, when needed. When the system works optimally, our revenue is protected. I also look for trends in terms of what’s rejected most often, and then I ask this question: How can we use technology to correct it?
What’s the best way to get started with revenue integrity?
Helmer: First, the organization needs to hire someone with a compliance and billing background to serve as the director of revenue integrity who can oversees the entire effort. Or the director of revenue integrity can combine efforts with a director of revenue cycle and both can work together as part of a larger team. Job descriptions for every member of this team should clearly state that they are responsible for protecting revenue integrity.
Second, organizations must audit their physician practices. Our policy is to audit practices annually. If practices meet the 80 percent accuracy threshold, our coding auditor/educator continues to audit them annually. If they don’t meet that threshold, we provide education and audit them every 90 days until they meet the threshold.
Finally, organizations need policies and procedures to explain how and why these audits occur and provide steps for corrective action. For example, policies should clearly state that when practices don’t meet requirements, representatives must attend educational sessions and undergo subsequent audits to ensure compliance. Policies should also include a plan of progressive discipline for practices that don’t follow the requirements and continually jeopardize compliance.
Getting started with revenue integrity also requires a mindset shift. Organizations need to look beyond production and focus more on quality. Staff should only touch a claim once. It should be right the first time so it goes out the door and is paid correctly and without risk of denial or recoupment. If it is rejected, that costs money because you need staff to fix it on the back end.
A reward system is also important. I reward staff with a gift card when they identify trends and come up with solutions to improve compliance. I promote this because it improves overall revenue integrity. In addition, I listen to my staff and don’t assume that I have all of the solutions.
Can hospitals support their practices in this endeavor and journey toward revenue integrity? If so, how?
Helmer: Yes, hospitals can launch a revenue integrity program first—and involve directors from the practices. We have a director of reimbursement and revenue advisory services, and our compliance officer is certified in revenue integrity.
In addition, hospitals should develop a compliance plan to ensure revenue integrity and create a separate compliance plan focusing on high-risk areas specific to this setting.
Interviewed for this article:
Darlene Helmer, CMA, CPC, ACS-N, CMPE, MGA, is director of revenue cycle for hospital-employed physicians, University of Maryland St. Joseph Medical Center, Towson, Maryland.