Three Functions Behind the Challenges of Revenue Integrity

Understanding the front-end, middle, and back-end functions of revenue integrity will help prevent common revenue integrity challenges. 

This is an excerpt from an article was originally published on Revenue Cycle Advisor on August 2.

As more focus is placed on improved revenue integrity management, coordination, and collaboration, revenue cycle is evolving to revenue integrity. As such, it’s important to understand the classic revenue integrity issues which can arise at any facility.

These core revenue integrity issues can be broken down into front-end, middle, and back-end functions of revenue integrity.

Front-end functions refer to patient access and eligibility. While patients may assume that services given to them are covered by their payment plan, this is not always the case. It is important to understand how to apply coverage policies to the providers’ services and the clinicians’ orders, says Elizabeth Lamkin, MHA, ACHE, in the recent HCPro webinar, “Challenging Classic Paradigms in Revenue Integrity”. She advises looking at whether the referral documentation supports coverage of the patient’s service per the plan’s policies, and for Medicare patients, access national or local coverage determinations.

Middle functions of revenue integrity include coding, utilization review, and case management. One issue facilities may encounter in terms of case management is managing continued stays. Valerie Rinkle, MPA, said in the webinar that she advises dedicating three minutes per patient in daily morning rounds to ensure the patient’s length of stay (LOS) is appropriate. Additionally, Rinkle recommends documenting and tracking reasons for excess LOS days for feedback improvement.

Back-end functions refer to patient financial services, and the back-end is where facilities will deal with edits when they occur. “Edits are missed opportunities for pre-claim edits or a correction of the root cause to prevent the edit altogether,” says Lamkin. In order to manage edits, Lamkin advises working through processes to see if the edit is a result a one-time situation or a repeated, procedure-to-procedure edit. Resolving these issues at the root cause is the best way to prevent running into future edits, she adds

For more information on these key issues, see Revenue Integrity Insider, a newsletter from the National Association of Healthcare Revenue Integrity.