The coronavirus pandemic has stress-tested revenue cycle management along with many other aspects of healthcare. We’ve seen adjustments to billing including coverage for testing and parity for telehealth. These changes have dramatically affected many practices’ revenue and created a dire situation; despite federal aid, 51 percent of primary care physicians “are uncertain about their financial future one month out.” With so much uncertainty and so many changes, revenue integrity can help to reduce confusion.
Health Leaders perfectly summed up how revenue integrity can be an anchor during unprecedented times: “While many regulatory waivers have been issued to allow for flexibility in responding to the public health emergency, they did not excuse inaccurate or incomplete documentation from being a target for review and denial by payers. By uncovering missed documentation, coding, and query opportunities, the pre-bill process drives revenue integrity, mitigates financial risk, and secures future revenue.”
What Is Revenue Integrity?
Revenue integrity consists of policies and processes that ensure correct reimbursement and compliance. The Healthcare Financial Management Association defines revenue integrity as a focus on “better coding and charge capture, in particular, to reduce the risk of noncompliance, optimize payment and minimize the expense of fixing problems downstream with claim edits.” To ensure integrity, a revenue team proactively identifies and detects anomalies, then swiftly corrects any errors. This correction process uses sophisticated software to run claims payment data versus expected reimbursement. However, there is a human dimension as well; revenue cycle management teams need to develop working relationships with payer representatives that they can leverage when requesting claims reprocessing. Enhancing revenue integrity often operates at a cross-functional level, uniting several disciplines: revenue cycle management, credentialing, payer negotiation/partnership, implementation, and performance management teams, and more.
The Goals and Challenges of Measuring Revenue Integrity
Revenue integrity is made up of many variables. For example, revenue integrity measures include:
- Percent of valid payments – Evaluating whether a payment meets expectations and contractual agreements
- Identification and appeal of underpayments – Spotting instances in which the payments are less than the contracted amount
- Denials – Grouping denials by payer and denial type to notice trends
- Chargemaster maintenance – Ensuring charges are set appropriately above the highest expected reimbursement
- Payer policy and reimbursement changes – Monitoring and communicating changes with stakeholders
- Payer and practice audits – Auditing both contract performance on a payer-by-payer basis as well as payer performance from a practice perspective to identify areas for escalation or training
Given the quantity and complexity of these metrics, ensuring revenue integrity is difficult and daunting for many practices. The process is time-consuming. The contracts and terminology can be incredibly confusing. Reimbursement rules vary by both payer and product. Patient insurance must be input correctly in order for systems to identify whether claims are paid accordingly. Finally, the tools and software that can assist with revenue integrity, such as Trizetto, are expensive.
Revenue Integrity and COVID-19
It is readily apparent that revenue integrity requires a high degree of expertise, time, and attention. This is especially true during the COVID-19 pandemic. Using an agile framework to measure progress and audits can help make sure that contract loads, changes, and audits are prioritized and delivered on. To optimize revenue integrity during these unprecedented times, Privia Health’s Jeanette Wood, Vice President of Revenue Cycle Management, and Amy Waller, Vice President of HIM and Coding Integrity, identified the four key components of a COVID-19 billing and coding workbook: detailed, scalable, user-friendly, and dynamic and flexible.
These core components underscore a robust revenue-integrity process. As Jake Morris, Managing Director at Navigant, noted pre-pandemic: “Revenue integrity should be the glue that binds clinical operations with coding and business office functions. It’s clear that the providers with established [revenue integrity] programs are benefiting from them, and expanding their scope will help yield long-term financial reporting reliability and operational efficiencies.”
By utilizing these tools and processes, revenue integrity can help practices navigate the unpredictable future with more confidence.