As health systems face already-tightening operating margins, additional reductions in reimbursement, and the competing demand for an increasing focus on the patient experience, health systems are looking to control risks and maintain financial stability. Revenue Integrity programs, the conduits through which clinical departments and their revenue cycle colleagues promote integration to improve charge capture and reduce revenue leakage, are the solution. While a majority of large-scale health organizations recognize the need for a robust and proactive Revenue Integrity program, the form and protocols of existing programs vary dramatically by organization. A driving factor of this variation is the technology infrastructure, which ranges from home grown legacy systems to single integrated electronic health records (EHRs). As more organizations invest in integrated clinical and financial accounting systems like Cerner and Epic, the charge capture paradigm is shifting from reactive back-end functions to proactive clinical end user resolutions.
Regardless of any health system’s particular sensitivities, EHRs provide a path for all health systems to implement the most fundamental standardized practices.
Revenue Integrity Service Line Structure and Skill Mix
Because coding and billing guidelines are specific and align with the clinical services performed, building the Revenue Integrity team’s subject matter expertise for targeted service lines is an important first step when engaging with clinical leadership. This service line approach, which would span departments like Cardiac Cath Lab, Emergency, Infusion Services, Operating Room, Outpatient Clinics, and Radiology, will promote consistency and collaboration with clinical counterparts. For example, Interventional Radiology and Cardiac Cath Labs are both revenue generating and high impact service lines due to the complex procedures performed. A Revenue Integrity liaison that understands their complex documentation and coding guidelines, enhances collaboration and outcomes.
The skill mix of the Revenue Integrity team is as important as the structure that is employed. A strategic blend of clinical experience (e.g. RN), coding/billing regulatory knowledge and analytic problem solving skills is highly recommended to drive both compliance and optimized revenue capture. While many programs focus on candidates with revenue cycle background, it is also important that candidates understand the clinical operations and workflows to identify enhancements in the charge generation process. Candidates with the ability to analyze and interpret data analytics is an important skillset as EHRs enable more dynamic reporting capabilities to monitor and track revenue at various points of entry.
Ongoing Clinical Education Program
A well-designed Revenue Integrity program includes education focused on charge selection tools and rules specific to the clinical department. Oftentimes education focuses strictly on memorizing CPT codes, where in reality it should be geared towards helping end users understand how documentation is linked to billable services and assist with the translation between clinical care and billing requirements.
With increased demands and slimmer resources, clinicians are eager to have more accountability and ownership of their department’s budget. Clinician focus on revenue performance therefore creates a unique opportunity for maximum clinician buy-in and for direct communication between clinicians and revenue cycle professionals. Focusing on documentation integrity as a mechanism to accurately reflect the services rendered and care provided improves timely charge capture and clean claim rates.
Clinical education should be ongoing and collaborative. With constantly changing regulatory and coding guidelines as well as advancing technologies, bidirectional communication is key. The Revenue Integrity team can provide regulatory and coding updates while clinical leaders can discuss strategic plans for expanding services and/or technologies necessitating a review of charging methodologies.
Revenue Monitoring and Reconciliation
At its inception, any Revenue Integrity program should include disciplined understanding of revenue capture, projections, and regular review of program progress and effectiveness.
It is challenging to dive into any type of trends in data without defining clinical departments’ revenue baselines and goals. Revenue monitoring starts with understanding each service line’s monthly projected and actual revenue for 12-18 months. Such analysis of revenue goals requires a triad approach—involvement of financial team, Revenue Integrity and clinical stakeholders–in order to provide comprehensive approach to monitoring. Charge reconciliation and revenue monitoring should utilize reporting tools to promote accurate charge capture, as well as early and efficient issue detection. Lastly, revenue integrity departments should assess and review clinical processes for charge reconciliation including policies and procedures, providing enhancements to reporting structures based on leading practice examples.
In addition to revenue monitoring, which includes not just a macro-level analysis of revenue performance, leading practice Revenue Integrity strategy for optimal performance includes a focused, strategic risk-based assessment methodology. The methodology includes but is not limited to complexity of services provided, source of CPT coding (hard vs. soft coding), strategic value, late charges, staffing and staff turnover, charge capture methods, and charge reconciliation tools/practices. Each metric can be weighed, resulting in risk assessment index assignments based on the clinical department(s) total revenue and volume. The output of both the risk assessment and revenue quantifications outlines a high level roadmap for the Revenue Integrity program to prioritize initiatives across dynamic and variable service lines.
Workqueue / Edit Management
Although Revenue Integrity programs promote proactive revenue management strategies, exception-based revenue integrity pre-bill edits provide a safety net to catch charge capture errors. Examples of exception based edits include paired services missing a component and inappropriate assignment of comparison codes. Errors such as these can be tracked and trended to facilitate process improvements upstream as well as identify sustainable solutions.
To most effectively manage revenue integrity edits, it is important to develop comprehensive policies and procedures. End-users must be held to productivity and quality standards to ensure accurate claims being sent timely to payers. These policies and procedures should also outline the escalation process of end-user feedback to communicate issues and trends. And it is important to structure resources for continuing education, training and updating the edit content.
Although health systems should feel latitude to decide how to implement a Revenue Integrity program, best practice includes (i) aligning revenue cycle professionals with the right skill-set across service lines, (ii) promoting ongoing and collaborative education of revenue integrity fundamentals, (iii) disciplined goal-setting and evaluation for proactive revenue management, (iv) utilizing risk-based assessment methodology to prioritize service line initiatives, and (v) trending exception-based edits to facilitate upstream process improvements.
 Charge Capture is generally defined as the process for accurately documenting visit and service information as well as corresponding charges and the timely and accurate posting and reconciliation of those charges.
 Revenue Leakage is missed or “lost” revenue
 These practices do not include the scope of Charge Description Master (CDM) functions
About the Authors: This post was authored by Emily Shaw – Manager, PwC; Kathryn Burg Plaza – Director; PwC, and Margaret Murphy – Experience Associate; PwC.
© 2018 PwC. All rights reserved. PwC refers to the US member firm or one of its subsidiaries or affiliates, and may sometimes refer to the PwC network. Each member firm is a separate legal entity. Please see www.pwc.com/structure for further details.