Revenue Integrity

Revenue Integrity Important?

Revenue integrity (RI) has been a buzzword lately, with health care providers looking to reduce costs and improve patient care. It has meant different things to different organizations, but ultimately, the basic definition is very specific: to make sure that each clinical encounter is properly translated into actual revenue, utilizing methods that focus primarily on overall revenue efficiency, compliance, and optimum treatment for patients. However, revenue integrity in the medical realm is much more than pie-in-the-sky talk. It’s about taking the information you collect in your office and ensuring that it is correctly shared with those responsible for billing. More than just making sure you’re collecting all the data you need, though. It means ensuring that you’re acting ethically when it comes to charging your patients.

How does a practice achieve revenue integrity? Many measures can be taken to ensure you aren’t violating the rights of your patients or those who oversee your care. One of the easiest, and least expensive, measures is to establish good clinical practice guidelines. These should include not only policies regarding pricing, access, billing, and reimbursement but also patient education about appropriate clinical practices. These guidelines not only help to prevent bad practices from taking place, but they also help ensure that good one don’t.

Some smaller healthcare agencies try and solve their revenue integrity problems by themselves, such as when it comes to coding, billing, and insurance. Unfortunately, without an expert team on hand, these efforts can be quite ineffective. The task of improving coding practices often falls on the shoulders of junior staff, who aren’t experienced with the complexities of coding procedures or the intricacies of billing procedures. As a result, sometimes practices can miss mistakes due to oversight rather than because of coding errors. Another way that junior staff can fail at improving clinical quality and compliance with insurance claims is by simply accepting the guidelines given by upper management and staff without modification.

Improving coding practices can also help reduce overhead and administrative costs because they increase productivity. However, not all coding changes are saved simply because of increased productivity. Often time-consuming or costly changes, such as changes to codes related to new diseases, are needed. For a chance to be accepted by the Revenue Integrity professionals, it has to pass several quality review criteria. Changes to coding which aren’t necessary, ineffective, or time-consuming often get rejected.

Revenue Integrity professionals

When Revenue Integrity professionals work in conjunction with Quality Review teams, they have the opportunity to identify unnecessary expenses and suggest ways to save money. This includes eliminating the need for redundant tests, testing that isn’t needed, and tests that are conducted too often. In addition, Revenue Integrity professionals can make changes to coding that directly affect the revenue cycle. Eliminating the need for tests that provide results in the health system or reimbursement process can save a lot of time and money. Sometimes changes to the codes and documentation for tax credit processing can reduce the number of tests required for tax year submission and reduce the amount of time spent on each test.

Revenue integrity groups also play an important role in the selection of the best software for managing healthcare systems. The software selected must meet the requirements to qualify for reimbursement. Improper selection can result in inaccurate data, inaccurate reports, and a lack of knowledge about trends in the coding of health claims and the overall revenue cycle. Revenue integrity groups often choose to use the most appropriate software available rather than choosing the most expensive one for the given situation.

Some healthcare organizations want to work with Revenue Integrity representatives, but don’t know of any local representatives in their area. In this case, an independent representative might be needed. Healthcare organizations should encourage their internal representatives to join the Revenue Integrity Association. Revenue Integrity Association members have the opportunity to attend national meetings that bring together those in the healthcare industry, specifically tax professionals, management teams, system designers, auditors, and other important individuals. Healthcare organizations should encourage their local representatives to attend these meetings to learn from the experiences of others in their area who are also associated with the association.

Revenue Integrity

Revenue integrity groups should ensure they provide training to their members on billing and audit processes, quality improvement, audits and collections, and accounting procedures. They should train their members how to document their results, keep accurate records, and how to follow the tax code requirements for submission and collection of federal and state income taxes. Healthcare organizations should encourage their RI specialists to work with their local auditors and their code inspectors. Revenue audits should include a discussion of audited financial statements and a review of the company’s billing and collections procedures along with explaining why those processes are necessary and why the current processes are no longer necessary.