The processes by which medical claims are submitted to insurers for payment have been on...
Overview
Revenue integrity programs exist across all kinds of healthcare facilities, from small practices to major hospitals. Although this practice may not seem as important as diagnosing and treating patients, it is vital. Without revenue integrity, healthcare facilities would be unable to provide care for patients. This is why revenue integrity programs are becoming more and more critical across healthcare.
Revenue integrity is an essential concept in healthcare. It refers to using ethical policies and practices to achieve compliance, operational efficiency, and optimal reimbursement. Medical facilities have to maintain a balance between these three factors so that they avoid inaccurate billing while at the same time making sure that they are not under-billing for the services they have provided.
What is Revenue Integrity?
Until a few years ago, the term “revenue optimization” was common in healthcare. This phrase was gradually phased out as the emphasis shifted from reimbursement and encompassed legal compliance and transparency.
Reimbursement for medical services comes from multiple sources, patient, state, and federal. The rules differ for each and can sometimes vary between individual patients. Maintaining revenue integrity keeps an ethical balance between reimbursement, compliance, and quality outcomes. While the impetus to increase revenue is strong within medical practices, the necessity to comply with regulations maintains revenue integrity. It also highlights how complex this maintenance can be.
The Benefits of Revenue Integrity
The benefits of having revenue integrity in place are many, particularly as medical practitioners have to deal with increased overheads and decreased ROI.
- Optimized workflow: revenue integrity has led to reduced accounts receivables.
- Standardized processes: shared uniform processes eliminate repetitive problems.
- Improved denial management: claims can be easily automated to speed up reimbursement.
- Enhanced compliance: this benefits every part of the revenue cycle.
- Improved charge assurance: attesting that all charges for medical services are correct.
Revenue Integrity Best Practices
Forward-looking healthcare organizations are starting to implement revenue integrity roles and programs. They aim to link clinical operations, medical billing staff, and the business office. Because revenue integrity highlights optimum coding and charge captures, it also reduces the risk of non-compliance.
Here are some best practices you can use to implement revenue integrity in your medical practice:
Any team member who uses the information system needs the training to be a charging expert. Linking your EHR to your integrity program is crucial for optimizing your workflow. When your team is focused on revenue integrity, they will retain an understanding of the importance of charge ownership. This will enable them to identify the best-suited team members for each task within the integrity cycle.
Once you have trained your staff and your organizational structure is in place, you’re ready to develop a timeframe to get your revenue integrity program up and running. Typically, this will be twelve weeks. By dividing your timeline into three, four-week periods, you can implement three phrases. These are:
- Discovery: An examination and evaluation of your current position.
- Vision: Establishing your goal and mapping your journey.
- Completion: Implementing your plan and seeing it to fulfillment.
Next, you need to put organizational tasks in place, for example, annual compliance reports and evaluations of your revenue integrity program. You may also want to pay special attention to areas that may be highlighted for external audits and areas that have previously been included in OIG inspections.
Data analytics is a crucial factor in any revenue integrity program, whatever the size. With the right technology, you can gather and analyze information and get to the essence of your revenue integrity and quality of care. The important thing is to have the right technology in place and experts who know how to use it and implement the insights the information provides.
For those healthcare systems that have developed Revenue Integrity programs, the results are significant. More than 68% of executives surveyed reported increased net revenue collections, with 61% reporting an increase in gross revenue collection. In addition, 61% reported a decrease in compliance risk after establishing a Revenue Integrity program.
Revenue Integrity FAQs
Why do I need a revenue integrity manager or department?
Whether you need a revenue integrity manager or department will depend on the size of your healthcare facility. However, having one or more people on your team who specialize in the field means that they can focus exclusively on revenue compliance and quality of care.
What is certification in revenue integrity for healthcare?
The Certification in Healthcare Revenue Integrity (CHRI) is a certification awarded to an individual who is qualified to provide this service in a healthcare setting. The credential ensures that healthcare revenue integrity professionals are recognized for their competence and expertise within the field. If you are looking to add members to your team before implementing a revenue integrity program, you can count on individuals with CHRI credentials.
Why you Need a Revenue Integrity Program in Place
Establishing revenue integrity within your healthcare practice culture can seem a little daunting. However, the effort required will significantly increase your chance of success. What’s more, you will begin to see the benefits in a relatively short time.
According to a 2017 HFMA survey of 125 medical facilities’ revenue executives and CFOs, 22 percent claimed that revenue integrity was a top priority. Despite this, fewer than 50 percent said that their facilities have revenue integrity programs. However, those who have a plan in place report the following:
- 61% reduction in compliance risk
- 61% overall gross revenue capture
- 68% increase in net collection
If you don’t already have a revenue integrity program in place at your hospital or medical practice, it’s easy to see why you should implement one as soon as possible.
How can we help.
PrognoCIS is a healthcare technology company serving the needs of healthcare practices of all sizes and specialties. Part of our platform of features includes integrity management services. Contact our team of experts today to determine how your medical practice or hospital billing can benefit from revenue integrity.
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