Here’s how various stakeholders may view revenue integrity:
- Quality officer: Patients are at the center of the revenue cycle. When it comes to revenue integrity, the quality officer needs to ensure that the patient experience— including outcome quality, acuity of care and the requested reimbursement— is accurately reflected in the final bill.
- Compliance officer: True revenue integrity depends on strict adherence to all laws and regulations. These can change frequently, so what worked yesterday may no longer be effective today. The compliance officer should develop reports that show how new regulatory developments impact the organization’s processes and overall revenue cycle, and work with each stakeholder to adjust accordingly.
- Coding director: The coding department is also focused on compliance, though from another angle. It’s up to the coding director to support the coding staff as well as any clinical documentation improvement programs in a manner that aligns with revenue integrity goals.
- CFO: The responsibility of allocating resources throughout the organization often rests on the shoulders of the CFO. He or she should be able to develop an accurate representation of what level of revenue integrity is being achieved, what opportunities exist in terms of addressing it, and the respective impact of each.
- Physician: Doctors play an important role in the revenue cycle, because the billing process starts with their initial documentation. Physicians have a role to play in optimizing patient engagement by accurately documenting care and quality measures, and interfacing with the HIM/coding department, when necessary.
Keeping everyone pointed in the same direction requires greater transparency and communication between departments and an acute attention to detail. It starts with a plan, but without the right technology, executing that plan can be an insurmountable task.
Using technology to improve revenue integrity
Conducting internal coding audits to improve accuracy prior to bill drop can create delays in addition to being very costly. Post-billing audits are equally constrained as they tend to be on small, random samples of cases. This retrospective feedback occurs after the denials or compliance issues have occurred, which means root causes go unaddressed and efforts are limited to reacting to— instead of preventing—the accuracy and efficiency issues that hinder revenue integrity.
The answer here is to put the intelligence of keen auditors into a machine in a highly focused manner. Expert rules and pattern recognition on historical auditor data (AKA, machine learning) can represent a quantum leap for a revenue integrity program. Using automated scanning, all coding can be analyzed prior to billing. Those cases that have questionable code combinations are flagged for review, while those within an acceptable accuracy range can flow through to billing. It’s a more manageable way to screen all encounters, while enabling optimal use of resources on the highest priority cases.
In many ways, automation can be the key to achieving revenue integrity. As government regulations and payment methodologies become increasingly complex, it becomes difficult for hospital administrators, coding staff and others to keep up. For every element of the revenue cycle that is underperforming, the impact adds up in terms of lost revenue, increased risk of RAC audits and underreported quality measures. For example, when it takes several days after discharge to produce a patient’s bill, and then weeks or even months to audit that bill, any mistakes within it are virtually set in stone. Even if it contains errors which cost the organization thousands of dollars, there’s often little anyone can do about it. The revenue cycle doesn’t take breaks, and revenue integrity —as well as overall financial performance—suffers as a result.
With integrated technology and automated solutions, every stakeholder within the revenue cycle becomes empowered to do their job and support revenue integrity. RCM solutions can free up resources so administrative staff can perform their jobs more quickly.
To learn more about how to optimize revenue integrity at your organization, visit StreamlineHealth.net today.