By Elaine Dunn and Vindali Vartak
If you ask 10 revenue cycle leaders what the primary focus of revenue integrity efforts should be, you might get 10 different answers. Some will bring up denials prevention, while others will zero in on denials resolution. Still others will point to proper documentation and others will focus on charge capture. To a certain extent, all these leaders are right, and a little bit wrong—none of them are describing the full picture. Revenue integrity is not confined to one part of the revenue cycle, and it is not a stand-alone function. In the truest sense, revenue integrity is an outcome. It is the result of a hospital or health system consistently and accurately accounting for the clinical actions and decisions occurring in the organization and converting them into financial transactions. To realize optimal revenue integrity, all the front-end, middle, and back-end processes that drive the outcome must be working as smoothly as possible.
Why does revenue integrity matter?
Since most health systems have an extremely narrow profit margin, and clinical operations make up a large portion of revenue and expenses, it is easy to see why realizing strong revenue integrity is vital. It essentially ensures a healthcare organization receives appropriate reimbursement for clinical encounters. When organizations don’t have solid revenue integrity, they not only leave money on the table, but may also experience compliance problems, which can have significant financial consequences. Conversely, well-tuned processes can bring financial benefits to the organization as well as operational advantages in terms of workflow efficiencies and effectiveness. Finally, and most importantly, strong revenue integrity can generate financial resources that can be funneled back into mission-critical objectives, such as buying state-of-the-art clinical equipment, hiring additional doctors and nurses, opening new care verticals, and so on.
The pain points in the current approach
Unfortunately, most healthcare organizations struggle to realize an integral revenue process. Siloed operations and technology make it challenging to share information and uncover the root causes fueling performance shortfalls. The many manual processes add complexity as they are often slow, error-prone, and not conducive to easy data exchange. Even technology that was meant to streamline operations can have the opposite effect if it requires constant upkeep and rule tweaking. The reality is that most organizations have breakdown points throughout their revenue cycle that can lead to suboptimal revenue integrity. To make meaningful improvements in this area, healthcare organizations need to rethink their strategy.
A cultural shift is needed
To move away from the idea that revenue integrity is a function-based, department-specific set of tasks to be completed, and instead view it as an outcome to achieve, organizations need to change their mindset. A first step in this cultural transformation is to commit to becoming more proactive about problem solving, shifting away from reacting to issues and towards doing jobs right the first time. Right now, most organizations handle issues after the fact, which can be resource intensive, time-consuming, and not always effective. For example, many in the industry are still engaged in denials management instead of denials prevention, which can slow cash flow, limit revenue, and lead to increased bad debt. Not only can a more forward-thinking perspective avoid these negative ramifications, it can ensure that the organization is setting itself up for success from the start, catching issues early, and preventing problems from happening so they don’t adversely impact revenue integrity.
As part of this work, leaders need to look more holistically at revenue cycle operations and consider how their people, processes, and technologies become more preventive. A tactical strategy is to rethink the role of the revenue integrity team. Instead of having them operate independently and fix issues on the back end, organizations may want to embed team members throughout the revenue cycle, with staff working in different areas but still keeping a broader perspective. This allows team members to spot issues that cross functions, and breaks down siloes between departments, improving the connection points between teams, resources, and technologies. By weaving revenue integrity staff throughout operations, organizations can start to optimize processes earlier, which strengthens revenue integrity outcomes. When team members are given action-driven analytics that serve as early warning signs to potential problems, organizations can be more proactive and more reliably prevent downstream effects.
Transformation is easier with the right partner
To fully reimagine what’s possible, it can be helpful to work with an outside partner that has the depth and breadth of experience and familiarity with best practice—along with comprehensive data and technical assets—to enable meaningful change. This resource can work with an organization to comb through existing functions and see how current people, processes, and technologies support, or don’t support, revenue integrity as an outcome. Areas to explore with a knowledgeable partner include patient access, financial clearance, documentation, charge capture, and denials prevention. The right outside expert can deliver both the latest technologies and data analytics tools as well as expert staffing resources to operationalize new workflows and ensure best practices. By working with this type of partner, organizations can lay the foundation for more consistent and robust revenue integrity, baselining and benchmarking their performance, and cultivating nimbler operations that can effectively respond to changing healthcare dynamics.
Elaine Dunn is vice president of Revenue Integrity at Change Healthcare. Vindali Vartak is senior director of Advanced Analytics at Change Healthcare.