Revenue integrity is crucial for the financial sustainability of healthcare organizations. Healthcare organizations can improve operational efficiency, compliance, and payment optimization by ensuring that programs and services are coordinated efficiently, compliant, and paid optimally. This article will explore the importance of building an integrated revenue integrity team, the challenges healthcare organizations face in managing payer audits, and how to implement an effective revenue integrity strategy.
Understanding the Importance of Revenue Integrity
The Need for a Collaborative Approach
Understanding the importance of revenue integrity is crucial for healthcare organizations to achieve financial sustainability. A collaborative approach is essential, as revenue integrity requires the involvement of various departments such as clinical operations, billing, follow-up, denials, coding teams, clinical documentation improvement (CDI), health information management (HIM), business office, and compliance and internal audit. Coordination is particularly critical in areas of overlap, like between CDI and coding.
By implementing a well-coordinated revenue integrity program, healthcare organizations can significantly reduce rework, improve efficiency, identify leakage areas, and simplify the implementation of correction plans. This collaborative approach is critical to optimizing revenue and ensuring the long-term success of healthcare organizations.
The Impact of Incomplete Records and Denials
The impact of incomplete records and denials on healthcare organizations must be considered. Denials are often a consequence of submitting incomplete records or records containing chart deficiencies. A lack of coordination among teams and insufficient monitoring or updating of electronic health record (EHR) templates are common causes of such incomplete submissions to payers. These issues not only lead to financial losses but also contribute to an inefficient revenue cycle.
Recent data indicates that organizations have experienced a significant increase in payer integrity audits—over 45% in the past several years. This surge has been accompanied by a 28% rise in medical record exchanges and a 19% escalation in costs associated with
mitigating compliance risks during information exchanges. In addition, industry reports show that the average denial rate for healthcare claims is around 5-10%, with some organizations experiencing denial rates as high as 15-20%. Moreover, the American Medical Association estimates that the cost of reworking a denied claim can range from $25 to $30 per claim, further emphasizing the importance of addressing incomplete records and denials.
Furthermore, a study by the Advisory Board found that 61% of denials are potentially preventable, and 90% are due to avoidable errors or conditions. These figures highlight the significant opportunities for healthcare organizations to improve their revenue cycle management and reduce the occurrence of denials through more effective collaboration, process optimization, and EHR template management.
Healthcare organizations must prioritize a comprehensive revenue integrity strategy to mitigate the adverse effects of incomplete records and denials. Organizations can reduce the likelihood of submitting incomplete records by fostering improved collaboration between departments, implementing stringent monitoring and updating processes for EHR templates, better-managing payer audits, and optimizing their revenue cycle. By doing so, they can also minimize the financial burden associated with denials and enhance the overall efficiency of their operations.
Building an Integrated Revenue Integrity Team
Healthcare organizations must build an integrated revenue integrity team to optimize their revenue cycle and achieve financial sustainability. By fostering collaboration and coordination across departments, organizations can effectively tackle the challenges posed by payer audits, reduce inefficiencies, and build a strong foundation for long-term success. Healthcare organizations can take the following steps to create an integrated revenue integrity team.
Leverage expert resources: Identify or develop an internal set of experts within core areas, including specialty service lines, to resolve problems that may arise and provide guidance.
Enhance cross-departmental knowledge: Identify key personnel who might benefit from job shadowing another department to improve team communication and understanding.
Establish regular communication: Implement regular calls with stakeholders from each department, including specialty service line experts, to review risk, audit reports, and denials and facilitate focused discussions on trending topics.
Stay updated on rule changes: Review annual changes to rules, including those specific to specialty-specific services, to determine potential new risks, impacts, and educational opportunities.
Utilize advanced technology: Adopt sophisticated tools for analysis and tracking to provide stakeholders, including those in specialty service lines, with the information they need while promoting alignment.
Implement automation: Apply advanced automation techniques, such as machine learning and robotic process automation, to perform repetitive and duplicate tasks.
Align with internal training programs: Explore collaboration with internal training programs and recruit experts on avoiding denials and managing audits in specific areas.
Monitor changes in rules and processes: Keep the revenue integrity team informed about changes to important rules, procedures, or treatments, especially those related to specialty service lines, to ensure compliance and mitigate risks.
By implementing these strategies, healthcare organizations can build an integrated revenue integrity team that effectively addresses challenges and ensures financial sustainability, including managing the unique complexities of specialty service lines.
Achieving Success with an Integrated Revenue Integrity Team
Strong and committed management and executive sponsorship are crucial for building an integrated revenue integrity team. Executive sponsorship ensures that the team's objectives are aligned with the organization's strategic goals, providing the necessary support and resources for success. With proper alignment and cohesion, the team can reduce rework, improve efficiency, identify leakage areas, and simplify the implementation of correction plans. To achieve financial sustainability and enhance patient care, fostering collaboration that extends beyond individual department goals is essential.
Summary
Healthcare organizations must focus on revenue integrity to achieve financial sustainability. By building an effective integrated revenue integrity team and prioritizing a collaborative approach beyond individual department goals, healthcare organizations can better manage the challenges presented by payer audits and improve revenue integrity. Implementing an integrated team approach, involving key personnel from various departments, and utilizing
advanced technology and automation tools can help healthcare organizations succeed in their revenue integrity efforts. In conclusion, prioritizing an integrated team approach to ensure revenue integrity is essential for healthcare organizations to optimize their revenue cycle, achieve financial sustainability, and ultimately provide better patient care. By fostering collaboration and coordination across departments, healthcare organizations can effectively tackle the challenges posed by payer audits, reduce inefficiencies, and build a strong foundation for long-term success.