Revenue Integrity: Leveraging Data to Enhance Collaboration Across the Revenue Cycle

What is Revenue Integrity?

Revenue integrity helps bridge the gap between coding teams, clinicians, and the business office. The focus is to ensure all patient encounters are accurately documented, coded, billed, and paid. Today’s provider organisations face numerous challenges that impede revenue integrity, including ongoing revenue cycle and HI workforce shortages, disparate processes and competing priorities within the organisation, and the complex, evolving payer and regulatory environment. These challenges lead to breakdowns in the revenue cycle which result in denied claims, significant rework, and lost revenue. While data and analytics and digital tools and automation can address some of these challenges, provider organisations must prioritise revenue integrity to achieve sustainable results. Revenue integrity is not a passive process. It involves formalised, continuous processes to identify and correct issues that lead to revenue loss or pose a compliance risk and ensures accountability throughout the revenue cycle. Through gap analysis, reconciliation practices, data analytics, and education, organisations can understand their pain points and develop consistent policies and procedures to support efficient, effective billing practices. Revenue integrity helps break down silos and promotes shared purpose and learning across all stakeholders, including clinicians, compliance, health information management, and revenue cycle.

Revenue integrity is essential to meeting organisational goals and objectives. Decreasing the loss in earned revenue and reducing compliance risks enables organisations to direct more resources toward patient care and improve operational efficiencies. There is no one-size-fits-all approach to revenue integrity, the panel notes. Some provider organisations have formal, centralised departments to assess and enhance revenue integrity across the system, while others take a more decentralised approach at the hospital, department, or practice level. Regardless of the structure, revenue integrity seeks to understand the denial and audit landscape and enhance claim quality. This helps optimise payment and reduces costly, time-consuming downstream fixes.

Audits and compliance checks are not substitutes for revenue integrity, the panel notes, because they often fail to identify emerging issues and account for changing clinician documentation practices. These processes are an integral part of the revenue integrity process, however, helping identify compliance risks and ensuring standards and procedures are up to date.

Overcoming Challenges to Revenue Integrity

The panel highlights top challenges to revenue integrity. Key among them is lack of access to actionable data to drive meaningful revenue cycle improvements. Greater data transparency is needed to secure data from disparate billing, operations, and compliance systems. Leveraging key performance indicators (KPIs) helps identify current and emerging risks so organisations can explore the root cause and take the necessary corrective action(s).

Workforce shortages remain a top concern. The lack of skilled, knowledgeable HI and revenue cycle professionals can lead to billing and compliance errors at a time when organisations can ill afford lost revenue. Through automation, organisations can streamline many front- and backend functions and redirect staff towards revenue integrity solutions. Provider organisations should actively upskill and reskill HI and revenue cycle staff to fill workforce gaps, the panelists suggest. This not only addresses the workforce shortage, it is also an effective recruitment and retention tool.

Provider organisations should seek technology solutions that drive revenue cycle optimisation. This includes adopting systems that support key functions throughout the revenue cycle, from pre-authorisations to coding accuracy to denials management. Revenue cycle automation creates a seamless experience for clinicians and patients, enabling thorough documentation, coding accuracy, and efficient billing. Return on investment is achieved through improved claims, enhanced revenue capture, and risk avoidance.

The Role of HI in Revenue Integrity

HI professionals play an integral role in achieving revenue integrity as they process and manage patient data throughout the patient lifecycle (from the point of access to final billing). Specifically, HI professionals ensure patient data is used correctly by auditing coding and billing for accuracy and compliance. HI professionals also support the charge description master (CDM) to maximise reimbursement, ensure compliance with both government and private payers, oversee denials management, and support clinical documentation integrity. The panel recommends HI professionals play a greater role at the point of documentation to reduce note bloat within patient records by eliminating unnecessary information that does not reflect the care provided. The role of HI professionals in revenue integrity will continue to evolve to reflect changing payment and regulatory requirements.

Continuous process improvement is a key component of revenue integrity. The panel notes several challenges to ensuring complete and accurate coding, including lack of automation ( e.g. computer-assisted coding), disparate electronic health record systems, varying payer rules, and the need for greater clinician education. HI professionals are leveraging data analytics to overcome these challenges. By tracking KPIs, including coding accuracy, number of queries, missed charges, and denials, organisations can identify and focus in on areas of opportunity to address revenue leakage. Benchmarking KPIs also sheds light on where to focus clinician and coder education to address areas of concern.

Leveraging Data to Enhance Collaboration

Leveraging data analytics is fundamental to revenue integrity. It supports informed decision making to change behaviors across the organisation that hamper revenue integrity and provides actional insight to enable sound policies and procedures to correct them. Essentially, data tells the story behind revenue cycle performance that can then be used to educate and exact change. Data bridges the gap between stakeholders and bolsters collaboration by building awareness and holding stakeholders accountable for results.

Conclusion

Revenue integrity is fundamental to success in today’s complex healthcare environment. It ensures a unified, systemic approach to revenue cycle optimisation, preventing revenue leakage and maintaining compliance. HI professionals play a pivotal role by supporting accurate, timely coding; facilitating clinician education; and efficiently managing patient information throughout the payment lifecycle. Data analytics supports continuous process improvement throughout the revenue cycle and supports collaboration among stakeholders, including clinicians, coding teams, and the business office. By painting a clear picture of operational performance, organisations can gain actionable insights and ensure every patient encounter is accurately converted into revenue in accordance with applicable laws and regulations.