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Optimizing The Revenue Cycle Through Revenue Integrity

Analysis  |  By Amanda Norris  
   July 25, 2022

More revenue cycle leaders are seeing that the addition of formal revenue integrity departments aid in expansion and return on investment.

Carle Health, a health system based in Urbana, Illinois, recently launched a formal revenue integrity department.

Staff had long performed revenue integrity functions, but the need for a formal department with dedicated staffing became apparent as the organization experienced rapid expansion, Alison Davis, CPC, CEMC, head of business office operations and revenue integrity at Carle Health, recently told the National Association of Healthcare Revenue Integrity (NAHRI).

According to NAHRI, the goal of revenue integrity is to prevent recurrence of issues that can cause revenue leakage and/or compliance risks through effective, efficient, replicable processes and internal controls across the continuum of patient care, supported by the appropriate documentation and the application of sound financial practices that are able to withstand audits at any point in time.

Adding a dedicated revenue integrity department makes sense for organizations looking to optimize their revenue cycles through ways other than just automation.

Traditionally, operations, compliance, and billing departments are siloed—with clear divisions between the people, processes, and platforms in the clinical, coding, and revenue cycle departments.

That setup doesn’t lend itself to easy solutions. Getting these disparate entities to work together throughout the continuum of a patient’s clinical experience is an important goal for optimizing revenue integrity, according to NAHRI.

Over the past year, Carle Health expanded from two hospitals, two physician practices, and several rural health clinics to an additional three hospitals and another physician practice.

“What’s become apparent is the complexity introduced into our structure,” Davis says.

“As we get charges into our different external systems, our lab or our radiology departments may be extending charges into Epic interface files through a separate system or process vs. charges that are coming right out of the Epic system through different modules within that platform. Making sure that they come in with the right identifiers, even the right entity, as well as professional vs. facility has definitely become something that we have to monitor and make sure that we’re on top of.”

That complexity led Carle Health to structure its revenue integrity program to house enterprise-level charge management. The revenue integrity department supports charge reconciliation across the health system and partners with clinical and operational departments to ensure the chargemaster is effectively structured to cover all coding, regulatory, and payer-specific requirements.

Revenue integrity also investigates opportunities to apply automation to support these goals, Davis says.

Currently, Carle Health’s revenue integrity department reports up through patient financial services (PFS). The long-term plan is to carve out revenue integrity to create a truly stand-alone department, Davis says.

Revenue integrity will continue to work closely with PFS, HIM, and denials management to support shared goals such as charge routing, edit management, payer billing, and automation.

Davis currently has 32 staff in her hybrid department. Seven staff members are focused on revenue integrity, overseen by a team lead and a supervisor. The team also includes two nurses who conduct revenue charge audits. As the revenue integrity department becomes more independent, Davis is hoping to round out staffing to include more coding and clinical knowledge.

Davis also plans to launch a report that will track revenue captured through all revenue integrity efforts.

Along with developing enterprise-level charge reconciliation policies, one of Davis’ primary goals for the department is launching an external system to support root cause analysis of late charges and other charge and claim edit errors and delays.

The system will allow the revenue integrity department to conduct more pre-claim submission reviews, pinpoint systemwide bottlenecks and errors, and implement root cause solutions to prevent recurrence, she says.

No single revenue integrity model suits every organization, but by viewing core revenue integrity functions through the lens of your organization’s needs, you can create a custom model for success.

To read this entire story, check out the NAHRI Journal

Amanda Norris is the Associate Content Manager of Finance, Payer, Revenue Cycle, and Strategy for HealthLeaders.

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