Healthcare organizations cannot expect to achieve financial sustainability without having a deliberate focus on ensuring revenue integrity. Only with such a focus can they deliver programs and services that are essential for coordinating internal efforts to maintain operational efficiency, compliance and optimal payment. For this reason, few finance or revenue cycle leaders would discount its importance as a function. Simply put, having a well-coordinated revenue integrity program is a hallmark of financially healthy organizations.
But the question is: What’s the best way to get there?
It starts with recognizing the whole ecosystem of departments playing a role in supporting this function. That includes, for example, the following teams: clinical operations, billing, follow-up, denials, coding teams, clinical documentation improvement (CDI), health information management (HIM), business office, and compliance and internal audit.
For revenue integrity to truly work, it is critical that all these departments fully collaborate to promote the concept in a way that extends beyond each department’s individual goals. Such coordination is critical particularly in areas of overlap, such as between CDI and coding. Too often, these areas are disconnected, resulting in issues ranging from increased denials to jumbled processes to a damaged bottom line.
To address these issues, an organization must build an effective integrated revenue integrity team. This effort necessarily must begin with a clear understanding of how an integrated team approach can help to curb denials, and the tasks the team must perform to achieve this purpose.
How connected teams can curb denials and duplication
Denials often result from releasing an incomplete record or one that includes chart deficiencies. When documentation is inappropriate, payers do not receive adequate information to substantiate claims. Disconnected teams and electronic health record (EHR) templates that are not monitored or updated regularly are common culprits behind the submission of incomplete records to payers.
For instance, HIM teams are the experts in releasing medical records and ensuring compliance and accuracy in the release. The best practice for business offices requiring records for claim adjudication or denials, therefore, is to use the appropriate templates and work with HIM. Effective collaboration between these teams ensures denial reassessments are accurate, appropriate, timely and transparent, with full awareness of exactly what should be released to the payer.
Everyone should be aware of the proper processes, procedures and workflows to help eliminate duplicative work. For example, a prepay audit worked by two different people may result in two departments sending duplicate appeals to the payer. Even more confusing, one department might call it a clinical denial, when it was really a coding denial, or vice versa. Such lack of coordination not only wastes time, but also removes the organization’s opportunity for a follow-up appeal if the payer limits the number of appeals an organization can file.
A revenue integrity team can take steps to help address such issues. Here are five questions the team should consider in its efforts to curb denials:
- In cases where there is a bolt-on IT system that contains information not included in the EHR, does that system contain data that should be included in the payer response?
- Do we have transparency into what records were sent, along with detailed information on the shipment to respond to potential payer pushback?
- What is the feedback process between HIM and the business office after health information is sent to payers?
- Are teams reviewing frequent sources of denials to help identify gaps in the process that might be causing problems? For instance, are deficient or incomplete charts regularly sent for claim adjudication?
- Are we seeing trends in denials that are based on service area or within specific documentation?
It is a best practice for leaders to keep such points in mind as they build the integrated revenue integrity team. But to ensure the team effectively promotes collaboration, leaders also should take time to identify which departments share overlapping tasks and expectations and then determine where revenue integrity comes into play within each of those departments.
6 essential tasks for an integrated revenue integrity team
Once assembled, an effective integrated revenue integrity team should embark on following six tasks, each of which involves distinct tactics.
1 Identify key personnel who might benefit from job shadowing another department. This approach might feel “old school,” but it is critically important. For instance, shadowing a case manager who works with commercial plans teaches team members from other departments about prior authorizations. Audit team members, in particular, can benefit from learning about billing rules and what is involved with rebilling.
2 Implement regular calls with stakeholders from each department. Such calls should be scheduled monthly, at a minimum. The calls should review risk alongside reports from the revenue integrity team or compliance team on results of audits — both internal and external — and denials. For instance, compliance could share quarterly results of its internal audits. Meetings should allow time for focused discussions on trending topics and eliciting input and knowledge from other team members.
Further, team members who have received denials or audit results they can’t appeal should share that information with the internal auditing team so that it can be put into an internal auditing tool. This step allows management to analyze the lost denial or audit, identify the root cause and find opportunities for improvement.
3 Identify expert resources or develop an internal set of experts within core areas. All areas have their limitations. Even compliance will have its blind spots. It therefore is essential that team members be able to turn to experts to help resolve problems. For example, when a team member becomes aware of new issues regarding home health or rehabilitation, the member should meet with a service-line team expert who understands the specific and more complex billing rules or code changes related to that issue.
4 Review annual changes to rules. For example, the team should routinely track changes to the inpatient prospective payment system, the inpatient-only list and the hospital outpatient prospective payment system to determine the potential new risk, impact and educational opportunities. They then should disseminate that information to ensure all departments make effective and appropriate changes.
5 Adopt sophisticated tools for analysis and tracking technology. Today’s revenue cycle has become too complex to allow for traditional analyzing and tracking of data across teams using Microsoft Excel spreadsheets. Cases and dollars are commonly lost in this way.
A recent study of healthcare finance and revenue cycle executives found that nearly 40% of organizations surveyed continue to rely on Microsoft Excel spreadsheets to track audits and denials, versus more advanced technological denial management solutions.a In addition, less than a quarter of organizations track trends related to clinically avoidable denials.
Using updated technology and audit tools on the same platform can provide all the stakeholders the information they need while creating alignment. Similarly, aligning technology vendors that cross between departments can help translate information and analysis into what’s valuable for each of the key stakeholders.
6 Apply advanced automation such as machine learning and robotic process automation to perform repetitive and duplicate tasks. The use of such technologies is instrumental in freeing up employees for more complex responsibilities that need human analysis and intervention.
Completing these six tasks provides the team with a foundation for expanding its reach and focus — aligning, for example, with additional areas such as clinical appeals teams, clinical EHR teams and specialty departments.
Give attention to specialties
Specialty service lines present unique challenges to revenue integrity. Rehab, home health, psychiatry and infusion therapy are common culprits for payer denials and audits. These areas often carry special documentation, coding and billing requirements.
There are also nuanced rules for managing and appealing cases within specialties. Psychiatry, for instance, requires extra security measures for releasing behavioral health information. The revenue integrity team should explore aligning with internal training programs and recruiting specialty team experts who can provide guidance on how to avoid denials and manage audits in those areas. Experts also can notify the revenue integrity team of changes to important rules, processes or treatments.
The upsides of transparency and teamwork
When the integrated revenue integrity team is aligned and cohesive, exceptional things can happen. Organizations will find that the team approach reduces rework, improves efficiency, makes it easier to identify leakage areas and eases the implementation of correction plans.
Although every team has its own specific goals, common threads across departments are needed with broader impacts for the entire organization. When overlapping team goals can be integrated and communicated, organizations successfully reach higher-level objectives more efficiently. Clearly, building an integrated revenue integrity team requires strong and committed management. But the upsides — including greater certainty and stability around payment — make it well worth the effort.
Need for revenue integrity is growing amid a rise in payer audits
The heat is on for hospitals and health systems when it comes to revenue integrity, driven by an increase in payment audits by payers. After a brief hiatus during the COVID-19 pandemic, Medicare, commercial and third-party payers have resumed such audits.b Although the audits are simply aimed at ensuring accurate claim payments, they can be labor-intensive and onerous for providers.c
Data shows that organizations have seen an increase of more than 58% in payer integrity audits over the past several years, even with COVID-19.d There’s also been up to a 34% bump in medical record exchange and a 21% increase in the cost involved in mitigating compliance risk in the exchange of information.
The upward trend in denials also was identified in October 2022 survey by Kaufman, Hall & Associates, LLC: Of 86 hospital and health system leaders, 67% reported an increased rate of claim denials. That is more than double the 33% who reported increased denials in 2021. In addition, 51% said they experienced an unfavorable change in payer mix, with a lower percentage of commercially insured patients. Another 41% reported an increase in bad debt or uncompensated care.
Consider that in 2021, more than
26 million Americans were enrolled in Medicare Advantage (MA) plans. As these plans increase membership, MA claims audits also will rise. That’s significant because a recent OIG report regarding MA plans that issued prior authorizations or denials of payments found that 13% to 18% of cases should not have been denied. Monitoring the auditors is essential.
Such increased scrutiny makes the consequences of disconnected teams even more acute. Revenue integrity goals, strategies and communications among the HIM, business office and compliance teams must be interconnected. These departments must be fully aligned on revenue integrity and retention plans, and they must share a firm understanding of the impact if efforts are not implemented effectively.
a. HFMA/MRO, Clinical audits and denials research report, April 2022.
b. See, for example, LaPointe, J., “CMS resumes RAC audits, other medical review activities,” RevCycle Intelligence,
Aug. 5, 2020.
c. Morse, S., “Payer payment integrity audits are a financial burden to providers,” Healthcare Finance, Jan. 28, 2020.
d. Data reflect findings of 2022 internal analyses performed by MRO.