Creating a Value-Generating Revenue Integrity Team

Updated on April 7, 2023

When health systems are immersed in data related to billing, denials, internal audits, and external payer audits, it can be overwhelming to track, manage, and process what is an overwhelming amount of raw data. Creating a value-generating revenue integrity team and pairing it with technology is the answer to harnessing that data and using it to positively affect the tight margins experienced by many healthcare organizations.

While this might seem like a bold statement, the only way to productively use your data is to employ sophisticated analytics that will provide actionable insights on how to improve billing compliance and maximize revenues.

Every health system looking to maintain a healthy bottom line must have a dynamic revenue integrity team. Still, the most skilled revenue integrity minds will face an explosion of available data; they need to know how to process and understand it. They also need a software platform to help consume, process, and crunch all that data so they can be productive.

Transparency First

With the right team and technology in place, you can focus your efforts on the best areas to mitigate the risk of revenue loss. The first thing required is total transparency in and integration of billing, denial, and internal and external audit data so overall risk can be properly assessed. In other words, you must look at more than just billing data and denial information. You must look at the bigger picture.

The data gathered must also be consumable. Those within revenue integrity must be able to understand what it means and how to use what is generated while avoiding billing compliance issues and maximizing reimbursements. To do this, you need technology that helps you make strategic decisions based on available data trends.  

Without technological assistance, data analysis is an unwieldy manual process reliant on information tracked in mumerous excel spreadsheets and on sticky notes. A solution that synthesizes all of the data and presents actionable insights and at-risk trends will point you in the right direction and put you in the driver’s seat to put out any fires. For example, instead of worrying about 1,000 providers’ billing trends, technology can help you identify the 200 providers who pose a risk to the organization due to regular overpayments and underpayments.

Technology can make all of the data in your system immediately meaningful and actionable. Your revenue integrity team can then use the findings to create processes and billing practices that result in better outcomes and improved revenue while reducing loss. 

Framing Risk Analytics

There are several factors to consider when developing a revenue integrity team that meets these objectives. First, you’ve got to be aware of the integrated risk signals created when looking at billing, denial, and internal and external audit data at the same time

Next, you must avoid creating billing compliance issues. For example, are you seeing anomalies in billing volume versus benchmarks? Is there a trend in billing outliers or other factors impeding your revenue cycle?

Some things to look for include frequent denials for a specific payer. What is causing the problem and is it coming from your billing, coding, clinical, or other department? An audit helps here, too.

Next is how to reduce any revenue leakage. Determine if you see the same target in multiple audits. Has their performance been improving? Are performance benchmarks being met? Is your education working? Of course, for internal education to work, you must conduct it. Use your audit findings to inform and provide regular education to appropriate teams.

Also consider how to enable faster payments – the core responsibility of any revenue cycle integrity team – by analyzing denial predictors such as wrong treatments recommended for the diagnosis or wrong drugs prescribed. Which payers are auditing your claims and why? The financial impact of these issues may be slower payments received. 

Finally, though no less important, building a high-functioning revenue integrity team is necessary for every healthcare organization that needs to generate revenue in a clear and systematic (yet correct and accurate) manner. An additional tip for creating such a well-oiled system is to take one more step and combine billing, denials, and payer data into your review processes.

Building the Team

Consider each member’s specific skills when creating a value-generating revenue integrity team. These include:

  • Expansive knowledge of the revenue cycle continuum
  • Subject matter expertise in payer adjudication policies and practices
  • A thorough understanding of CMS billing regulations and familiarity with the OIG work plan
  • Ability to assess data to develop and implement performance improvement opportunities
  • Expertise in conducting and interpreting qualitative and quantitative analyses, financial analyses, healthcare economic and business processes, information systems, organizational development, healthcare delivery systems, project management, and new business development.

Ultimately, the goal is to have a revenue integrity team capable of taking a broader view of revenue opportunities and risks and using technology to get the most from all available data. Doing so eliminates silos and allows everyone to work toward a common goal rather than having separate teams address the same issue differently. In addition, centralizing the flow of information makes it easier to see common themes and identify solutions to address challenges.

Communicate transparently 

Revenue integrity is a holistic approach that requires transparency so the combined expertise of revenue cycle and billing compliance professionals can be fully leveraged to manage financial risk for a more vital and resilient organization. Thus, breaking down communication silos is just as critical as eliminating data silos. 

Again, the key is having in place the right technology; software that engenders real-time communications within and between not just revenue integrity, but also any other departments that impact the revenue cycle. It also ensures everyone has access to the same information which they can then utilize as appropriate to their roles and responsilibities. 

By breaking down silos and enabling real-time communications between billing compliance, revenue cycle and other departments, technology enables your value-generating revenue integrity team to take the proactive steps important to the prevention of future risk.

Analytics Help Focus Efforts

Using analytics allows your revenue integrity team to better understand the organization’s current financial situation and allows them to determine with certainty whether planned changes will have the desired impact on revenue flow. For example, predictive analytics could be used to identify claims that will be denied and why, as well as how to fix them – all on a pre-bill basis.

Robust analytics also empowers your team to proceed with confidence that proposed changes will accomplish their intended goals, for example process improvements designed to improve first-pass pay rates while reducing the denial team’s workload. Analytics can also identify organizational trends requiring intervention. For example, if 40% of claims are denied one month, analytics can be used to catagorize those denials (e.g., by reason, area, payer, or provider), determine the root cause (e.g., a coder or documentation issue), and design the appropriate action. 

There are challenges when it comes to optimizing analytics, however. Even the most highly qualified team will struggle when it comes to  leveraging analytics without the technology tools to rapidly cull through massive amounts of data to identify trends, issues and root causes in order to properly prioritize decisions. 

Bandwidth and staffing are also signficant challenges ensuring the value-generating revenue integrity team you put in place can fully leverage analytics to positively  impact the organization’s revenue cycle. Left unaddressed, these particular obstacles can limit productivity and lead to burnout and turnover – both of which can quickly undo any progress made toward revenue integrity. Arming your team with the right technology tools will not only improve the organization’s bottom line, it will also keep your revenue integrity team engaged, productive, and successful. 

Closing Thoughts

Ultimately, your goal as a revenue leader is to build a revenue integrity team capable of taking a broader view of revenue opportunities and risks. Doing so eliminates silos and allows everyone to work towards a common goal. Rather than disparate teams addressing the same issues differently, you centralize the flow of information to make it easier to see common themes and identify solutions to address challenges.

Assembling the right people is the most crucial element of creating a value-generating revenue integrity team, but other things will determine success. Other influencing factors include communication, performance benchmarking, analytics, accountability, and visualization, and using a technology solution that consumes and makes all data collected actionable.

Dana Finnegan
Director of Market Strategy at MDaudit

Dana Finnegan is Director of Market Strategy with MDaudit, a leading healthcare technology provider that partners with the nation’s premier healthcare systems to reduce compliance risk, improve efficiency, retain revenue, and enhance communication between cross-functional teams. Finnegan’s multi-faceted background includes more than 20 years of experience in healthcare revenue cycle and revenue integrity. His provider-side experience includes positions with Mass General Brigham and other large academic institutions. On the payor side, he worked at a small Massachusetts Medicaid provider and at the commercial carrier Athena.