What is revenue integrity, and how can your medical practice achieve it?
In the past, becoming and staying profitable was all about revenue optimization—that is, billing for and collecting as much as possible without much (or any) consideration of legal and contractual compliance. However, more recently, practice managers and other revenue cycle industry experts have moved away from this revenue cycle management (RCM) strategy that tends to promote over-coding. Instead, they use the term revenue integrity—the idea that you bill and collect everything to which you’re entitled—no more, no less.
In this article, we’ll define healthcare revenue integrity, discuss why it’s important, and provide four strategies to achieve it in your medical practice.
What is healthcare revenue integrity?
The National Association of Healthcare Revenue Integrity (NAHRI) says the goal of revenue integrity is to “prevent recurrence of issues that can cause revenue leakage and/or compliance risks through effective, efficient, replicable processes and internal controls across the continuum of patient care, supported by the appropriate documentation and the application of sound financial practices that are able to withstand audits at any point in time.”
Healthcare revenue integrity is less about maximizing healthcare reimbursement and more about being compliant with the understanding that revenue cycle compliance always leads to appropriate payment.
Here’s another way to think about it: When focusing on revenue integrity, you typically strive to ensure the medical codes you report accurately reflect the medical services rendered. Although you clearly want to bill and collect the maximum amount, there’s a big caveat: You must be able to clearly justify whatever you bill and collect. When you strive for revenue integrity, here’s what you don’t tell yourself: ‘I’m going to try and get as much as I can for this visit.’ Instead, you say, ‘I’m going to try and do the right (and compliant) thing knowing the proper reimbursement will follow.’
Why is healthcare revenue integrity important?
It’s a hard lesson to learn: Revenue optimization efforts may increase reimbursement in the short term, but you’ll probably also face costly denials and fines in the long-term. You’ll probably also face problems with patient retention. Imagine a scenario in which you consistently overbill your services, causing patients with high deductible health plans to incur higher-than-necessary copayments. Revenue optimization is a slippery slope that can damage your medical practice’s reputation with payers, patients, and others. It can also hurt your medical practice financial sustainability. Promoting revenue integrity is the better way to go.
How can your medical practice achieve revenue integrity?
There are several ways to achieve healthcare revenue integrity. Consider starting with the following four strategies:
Leverage the right technology. To promote revenue integrity, medical practices must help RCM staff make the best decisions possible to follow the rules, policies, and regulations. That’s where technology such as built-in claim scrubbers, automated eligibility, denial management tools, and more can help.
Perform regular medical coding audits. Medical coding audits are essential for revenue integrity because they help identify potential revenue cycle errors or omissions. You can use this information to inform training, tweak RCM or clinical workflows, and more.
Promote a culture of revenue cycle compliance. Creating a culture of compliance means making compliance a central part of the overall learning strategy for your medical practice. Everyone within the medical practice should understand and support their role in ensuring healthcare revenue integrity. This includes front-desk staff who enter insurance and demographic information, medical billers and coders who submit claims, and physicians and other providers who document in the electronic health record. It also means creating revenue cycle policies and procedures to promote compliance and consistency.
Set and monitor key performance indicators (KPI). KPIs are also an important part of revenue integrity. Here are a few important KPIs to track: Overall coding accuracy, missed charges, discharge not final billed claims, coding productivity, denials, avoidable write-offs as a percentage of revenue, and underpayment recoveries.
Conclusion
Revenue integrity plays an important role in the financial sustainability of today’s medical practices. Learn how edgeMED can help and be sure to check the Healthy Snacks blog for more expert insights, best practices and industry trends.
