What is Revenue Integrity?

According to the National Association of Healthcare Revenue Integrity, “the basis of revenue integrity is to prevent the 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.”

But people often think about Revenue Integrity quite differently from this “cut-and-dried” definition. In fact, it’s become something of a hot topic. Some people think it’s simply a department that maintains the Chargemaster. Others view it as a more robust cross-functional team with insight and knowledge of the entire revenue cycle. As subject matter experts, they can identify and resolve gaps that cause revenue leakage. Here, at RoundTable Strategic Solutions, we view Revenue Integrity as a program, strategy and department focused on eliminating revenue leakage and maximizing reimbursement.

Several market trends have been influential in formulating our paradigm on Revenue Integrity:

  • As of January 1st, hospitals were required to publish their Chargemasters. Many were concerned about the implications of this transparency.
  • As such, there has been an increased focus on CDM pricing. Hospitals became focused on setting their prices to be market competitive while continuing to maximize reimbursement. Some recruited vendors to assist while others managed this review internally.
  • Likewise, we see that today’s market is experiencing an abundance of change and opportunity.
  • Telemedicine services are on the rise.
  • Population health and value base care are expanding.
  • Driving down cost is becoming a mandatory effort and the overall patient experience is getting an abundance of attention.
  • Data analytics, EHR optimization and denial prevention are also a primary focus.

What is included in a Revenue Integrity Program?

Although key components can be tailored by client, Revenue Integrity typically encompasses functions such as CDM maintenance, charge capture and recon oversight, edit resolution, and department/provider outreach. CDI and denial management can also reside in a Revenue Integrity department. Regardless of how you think about it, Revenue Integrity is an integrated team of highly specialized members with broad knowledge of the Revenue Cycle. They are focused on process improvement surrounding charge capture, denial prevention, revenue maximization and compliance.

How to build a Revenue Integrity Program that will make a difference?

If you’re seeking help with your Revenue Integrity program, we have the upmost confidence in our abilities to assist you. Our team consists of industry leaders who, over the last decade, have worked together inside healthcare systems and/or in a consulting capacity. These long-standing working relationships and deep understanding of strengths and style has enabled us to place the right leaders at the right organization at the right time. At the end of the day, we want to do what’s right for our clients while providing a unique perspective and creative approaches in helping to solve their revenue integrity challenges.