Revenue integrity: A better reimbursement strategy

July 20, 2016
By Brian Andrews, Senior Vice President & GM, Revenue Discovery Advocate,
Change Healthcare

Let’s face it: Provider reimbursement continues to increase in complexity. While it is fair to say that a certain amount of missed revenue has always been part of the bottom-line equation, today’s providers simply cannot afford to leave any money on the table.

For this reason, the industry is facing some growing pains around the concept of revenue cycle management (RCM). Declining reimbursement rates – coupled with an increasing patient balance problem – are heightening the need for an expanded look at the issue. Some providers are embracing broader, integrated revenue integrity models to drive efficiency, strengthen patient engagement, and optimize reimbursement.

Revenue cycle management vs. revenue integrity

The concept of RCM is not new. Most providers associate it with applying best practices for managing known processes such as patient access, claims submission, and billing in order to optimize revenue. While largely effective, RCM still results in revenue gaps because of the traditional workflow silos that exist within many provider groups. In most cases, healthcare organizations end up merely reacting to issues, one at a time, as they surface within the various stages of the billing and reimbursement process.

In essence, the revenue integrity approach ensures that providers can clearly identify, track, and realize the profit margins for the care they deliver. Through a series of integrated systems and processes, providers can detect and eliminate many of the pitfalls in traditional revenue cycle processes that are quickly becoming liabilities. These intricacies commonly show up when dealing with complex payer contract reimbursement requirements, or when working with patient populations that lack awareness of their health coverage and payment responsibilities. All too often, the end result is an undetected underpayment, a claim with missing charges, or an unnecessary write-off of a patient-owed balance.

Why revenue integrity?

Progressive provider organizations understand that comprehensive revenue integrity – driven by analytics and business intelligence – enables early identification and resolution of revenue cycle challenges. In fact, the business case for investing in the right systems, analytics, and services to circumvent or prevent revenue cycle bottlenecks and optimize reimbursement is an easy one to make because it directly and immediately impacts revenue and cash flow.

The key is having an end-to-end integrated platform in place that allows data and analytics to drive workflow design and performance – including the ability to dynamically refer accounts to a third-party partner and still incorporate key denial root-cause data back to the provider. This root-cause data triggers improvements in front-end processes to prevent future denials from occurring. Providers who have made revenue optimization a priority recognize the need for both insourced and outsourced processes. Creating a revenue integrity framework requires an operational platform that unites all revenue cycle activities and fully leverages data analytics. The next step is to use that information to generate more effective workflows to improve the bottom line.

Moving toward comprehensive revenue integrity

Best practice revenue integrity processes essentially take traditional RCM to the next level by using predictive analytics to drive smart workflows that integrate functions, such as coverage identification, charge capture, billing, denial management, and payment, in order to optimize revenues. Whereas a solid RCM strategy might include solutions and services that separately address each function, revenue integrity integrates them to produce more robust business intelligence. Data extracted from various stages of the revenue cycle powers automation that proactively identifies potential issues before they become problematic. Often, providers have access to information regarding a patient’s deductible balance, which begs the question: What are providers doing with that information?

The best response is to incorporate it into workflows to better educate and communicate with patients, securing more patient-responsible balances as a result.

In truth, most providers are not using all of the data that exists within their eligibility and claims networks. For example, the depth of data easily mined from an eligibility network is far greater than just the confirmation of a patient’s coverage. Similarly, providers can do more than work denials to improve bottom-line performance. They can eliminate certain denials by tapping into better data, utilizing predictive analytics, and striving for a more integrated process. That’s one example. Providers can also benefit from using analytics on the front end to improve charge accuracy. While editing tools are widely used to address concerns around clean claims, providers can take operations one step further and use predictive analytic tools in the workflow to ensure claims are coded accurately and eliminate the costly rework or missed revenue from undercharging or overcharging.

The new standard

An integrated revenue integrity approach is fast becoming the new industry best practice for optimizing reimbursement. Ultimately, this approach requires integration of all internal and external revenue cycle functions. Thus, providers need to identify partners with broad RCM capabilities and a willingness to establish a high-level relationship built on shared goals. Those who do – and who embrace these integrated platforms and partnerships – are well on their way to an improved financial future.