The health system achieved approximately 103 percent of gross target revenue within 30 days of each go-live date.
The concept of revenue integrity in care settings traditionally has been associated with chargemaster maintenance aimed at ensuring that each department’s chargemaster is updated with reimbursable charges that are easily locatable by clinicians and end users.
The ongoing shift to value-based care, coupled with reduced payments, has increased hospital and health system focus on effective and accurate pricing, charging, and coding. As a result, revenue integrity departments have expanded, often including all efforts to collect information across the continuum of care and ensure claim payments are received expeditiously and in agreement with complex payer contracts.
As Penn Medicine prepared for its electronic health record (EHR) conversions in October 2016 and March 2017, senior leaders believed the conversions could be catalysts to develop a formal revenue integrity department. Penn identified an internal director to own the chargemaster consolidation, but, as the conversion grew closer, additional support was needed to achieve the goal of returning to 100 percent baseline gross revenue capture within 21 days of conversion.
Penn engaged an outside consultancy to provide revenue cycle support for its hospitals that were converting to a new billing platform in two waves. Collaborating with the consultants and the billing system’s implementation teams, Penn set out to mitigate revenue and cash disruption during each go-live, particularly in the areas of charge capture, pre-bill management (i.e., coding and claim error resolution), and claims integrity.
In addition to measuring metrics at the go-live stage, Penn’s revenue integrity structure included standing revenue reconciliation committees at each hospital to review department charge capture daily. This step was vital to the success of the conversion: Ultimately, the revenue integrity department would support the committees’ clinical areas on a long-term basis to ensure sustainability.
In using the conversion to design the revenue integrity department, Penn assessed internal personnel, recommending roles that matched staff skill sets and fulfilling core revenue integrity functions.
5 Steps for Development
Penn shares lessons learned during its revenue integrity department development.
Understand the conversion scope and ensure staff can support timelines. Penn’s revenue integrity function had an exhaustive list of conversion responsibilities: chargemaster consolidation and validation with operations and finance, charge capture design and education, charging work-driver build (i.e., worklists that caught charge errors and worklists that contained lists of patients that required charge entry), revenue reconciliation policy development, report development and user training, and benchmarking. In addition, the department had an unclear scope of responsibilities, so it was difficult to prioritize.
As Penn assembled the conversion workplan, the scope was limited to critical efforts that would have minimal revenue disruption. Use of the outside consultants and the department representatives allowed for prioritization and a divide-and-conquer approach, helping to ensure all goals could be achieved.
Hold clinical department stakeholders accountable. Accountability starts with defining best-practice revenue reconciliation strategies in conjunction with executive leadership. After giving managers heightened revenue reporting capabilities and transparency via the conversion, Penn seized the opportunity for department managers to take ownership of their own revenue. The mantra was, “They know their charges. They know their services. They know their patients. They are closest to their revenue and should be able to own it.”
Historically, designated billers with coding backgrounds—or gatekeepers—followed up with departments via e-mail about charging errors. Financial discrepancies or shortages were identified by finance at month end, but departments were not involved in reconciling their own revenue.
With the new technology, departments would have tools to reconcile revenue daily and proactively identify discrepancies and root causes, allowing for charge error resolution without gatekeeper involvement.
Although decentralized charging ownership is consistent with best practices, communicating the shift to the clinical departments was challenging. Most of the clinical departments were subject to the EHR conversion from a clinical perspective only, so resistance to the added revenue reconcilation resposibilites was expected.
To ensure appropriate expectations were set, Penn’s system CFO sent an organizationwide memo to all clinical directors, informing them that clinical departments would be held accountable for their own department revenue. Hospital CFOs sent the same memo to their directors to reinforce the message and designate revenue leads, many with different backgrounds ranging from financial controllers to chargemaster compliance. As this vision was shared, the stage was set for the revenue integrity team to support the departments during the forthcoming journey.
Connect with each clinical department to socialize the road map and identify key partnership opportunities. The clinical departments’ anxieties regarding revenue ownership provided revenue integrity with the opportunity to be a change agent for the organization. To quickly engage with the departments, revenue integrity teams established three-day sessions with each hospital entity to begin transforming the clinical departments into revenue owners. The meetings resembled “speed-dating” and included these questions:
- Does the planned chargemaster look correct?
- How do you enter your charges today, and who enters them?
- Who reconciles charges?
- How many charges do you typically enter on a Monday?
Determine who is responsible if revenue is below budget. As revenue integrity met with department leaders, they began to better understand their concerns, workflow needs, and individuals to target for training. Following these initial meetings, revenue integrity prioritized the core activities to support the departments.
Define revenue integrity functions to support departments and eliminate revenue disruption. Fully integrated revenue integrity departments collaborate from the point of care to the back-end revenue cycle. But just as “Rome wasn’t built in a day,” such departments take time to fully mature.
Consequently, Penn’s revenue integrity team prioritized the items that would be critical to meet the goal of returning to 100 percent target gross capture within 21 days of go-live. The team addressed critical concerns from the departments and the corresponding revenue integrity priorities implemented to alleviate these concerns.
Revenue Integrity Concerns and Responses
Assess revenue integrity staff and create roles based on their skills. Six months of preparing and two months of controlling the conversion chaos had profound positive impact on departments’ confidence to own their revenue. The process also allowed leadership to assess revenue integrity department staff skills and identify others who could aid in building a best-practice revenue integrity department.
Post-conversion, Penn created the following revenue integrity job descriptions based on the skill sets that supported clinical departments through the conversion:
- Chargemaster coordinator—manages chargemaster requests, consolidation opportunities, and pricing strategy
- Charge capture manager—supports departmental charging workflows and coordinates system build updates with analysts
- Revenue integrity analyst—provides financial analysis of revenue discrepancies and maintains a revenue tracker to provide transparency
- Site liaison—based at each entity, works to identify and resolve charge errors that prevent billing
- Entity leads—for each hospital, holds clinical departments accountable for revenue reconciliation and acts as an escalation point
The conversion achieved 102.7 percent of gross target revenue within 30 days of each conversion go-live. More important, Penn developed a revenue integrity department unique to the health system, based on how it pivoted to support their conversion.
As Penn’s revenue integrity department matures, other functions are being folded into it, including denials management, clinical documentation improvement, charging audits, and payment validation. Penn expects to fill these roles with the change agents that helped integrate these functions with revenue integrity.
Jill Richards is revenue cycle director, Penn Medicine.
Gary Goldstein is managing consultant, Navigant, and a member of HFMA’s Metropolitan Philadelphia Chapter.
Rajiv Sheth is associate director, Navigant.