7 Steps to an Optimal Revenue Integrity Strategy
By Vasilios Nassiopoulos, Vice President of Platform Strategy and Innovation, Hayes
The pace of scientific advancement moves faster than ever, and today’s providers, by and large, are open to embracing new best practices and better approaches to medicine. When it comes to optimizing the bottom line, though, many physicians are hesitant to give up traditional manual approaches to revenue cycle management and embrace forward-thinking, data-driven revenue integrity models.
Yet, the stakes are higher than ever for taking a strategic approach to financial health. Today’s practices are facing some of the tightest operational margins in modern history, amid challenges brought on by COVID-19, a continuous decline in reimbursements, and the shift from traditional fee-for-service models to value-based care.
Additionally, compliance departments face an uphill battle with documentation changes associated with telehealth and the Evaluation and Management (E&M) Codes—an unfortunate reality as the Office of Inspector General (OIG), which was already upping its game in terms of oversight, recently announced its audit plans related to COVID-19 discharges.
Strategic planning in healthcare comes in many forms, and revenue cycle should be front and center as a priority. To ensure future success and sustainability, healthcare organizations should consider these seven steps to a healthy financial outlook.
Step 1: Use an established best practice to support internal analysis.
When considering financial health, the foundation should be built upon an understanding of internal weaknesses and strengths related to revenue cycle.Providers can consider such techniques as a SWOT (Strengths, Weaknesses, Opportunities, and Threats) or PEST (Political, Economic, Social, and Technological) analysis to assess how the following impact revenue cycle:
- Success factors
- Goals and objectives
- Organizational culture
- Core competencies
- Current conditions
- Service or technology portfolios
- Competitive and regulatory pressures and changes
- Functional business models and departmental alignment
Step 2: Identify strategic objectives that elevate revenue integrity.
As providers design a strategic roadmap, a holistic approach to revenue integrity should be prioritized. These forward-looking models reach beyond traditional revenue cycle management processes to ensure capture of all reimbursement opportunities. They are characterized by a proactive, data-driven approach to claims auditing that streamlines processes and fosters better collaboration between billing, coding, and compliance professionals to identify problems, educate staff and improve overall processes.
Step 3: Prioritize strategies that bring relevant players together.
Revenue integrity is built on collaboration. This means billing and compliance departments that have long operated in siloes must combine forces. Optimal strategies bring all key players together and create a single, transparent view into functions across the entire organization.
Step 4: Address the front- and back-end of claims processes.
A sound revenue integrity strategy marries the strengths of retrospective and prospective auditing.
Prospective auditing addresses problems prior to claim submission while retrospective auditing analyzes underlying problems following adjudication. This combination ensures revenue integrity teams can identify the root cause of errors and educate stakeholders to ensure clean, timely claims from the start.
Step 5: Take hold of the promise of technological advancement.
Revenue integrity processes are data hungry, and the reality is that manual efforts to comb through thousands upon thousands of claims lines are typically a non-starter.
Like so many areas of healthcare, the right technology infrastructure—that draws on the promise of artificial intelligence and natural language processing—can dramatically impact a provider’s ability to minimize financial risk, improve revenue retention and identifying revenue that might otherwise be left on the table. Platforms exist that promote shared monitoring and auditing processes between members of a revenue integrity team, and a framework of automation can support both continuous and proactive auditing (prospective) of claims before they are submitted and ongoing monitoring of delayed or denied claims (retrospective).
Step 6: Set goals and benchmark against peers.
Streamlined revenue integrity strategies that are supported by technology-enabled processes can help billing and compliance teams elevate strategies. Establishing metrics around high-risk areas within the revenue cycle can go a long way towards process improvement. Revenue integrity teams can look to key performance indexes that reflect industry best practices for benchmarking. Some areas to consider include clean claim submission, denial rate, bad debt reduction and days in A/R.
Step 7: Expand strategy to include risk-based auditing practices.
Regulatory compliance demands and heightened risk place enormous strain on resource-strapped healthcare organizations. Risk-based auditing—an approach increasingly embraced across provider organizations—allows healthcare organizations to deploy resources around areas of greatest risk.
Instead of taking on the rigors of auditing every provider in every area of care, this strategy audits a cross section, zeroing in on identified problem areas. This approach can pay dividends amid consolidation trends that often result in rapid onboarding of new, untested providers.
A Strategic Approach to Financial Health
Optimal approaches to revenue integrity are imperative to future success and sustainability for today’s healthcare organizations. Providers must elevate financial health through a strategic approach that prioritizes people, processes, and technology. Forward-thinking practices are wise to build strategy around the seven key steps to maintain a competitive advantage going forward.
Vasilios Nassiopoulos is Vice President of Product Strategy and Innovation at Hayes. A senior executive with over 25 years of healthcare experience, he possesses extensive knowledge of EHR systems and PMS software from Epic, Cerner, GE Centricity and Meditech.