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Achieving revenue integrity in a changing and complex climate

A Q&A about revenue integrity trends, challenges and effective strategies for improvement.

Achieving Revenue Integrity

Achieving sound revenue integrity has always been a cornerstone of any high-performing revenue cycle operation. But reaching revenue integrity goals within health care has become more difficult.

Hospitals and health systems are faced with increasingly challenging payer policies, reduced funding availability for revenue cycle innovation and the rising complexity of value-based care.

The conversation below with Renee Monahan, Senior Director, Optum Advisory Services, aims to uncover a clearer understanding of the nature of revenue integrity and the keys to mastering it in a demanding health care climate.

How do you define revenue integrity?

Currently, there is no well-established industry-standard definition for revenue integrity, but a new and more modern, broader vision of it is emerging in the industry.

Traditionally, revenue integrity included CDM — charge description master management — and potentially charge capture. CDM management addresses regulatory and market requirements in pricing policies, such as price transparency requirements.

For charge capture, key components include coding, clinical documentation integrity, charge capture technology, clinical charge entry and reconciliation and audit.

The new vision for a mature revenue integrity program includes all the traditional areas mentioned, as well as billing and edit management, and payment variance management — both denials and under- and overpayments.

What are some of the key revenue integrity trends health care providers should be aware of?

Value-based care has changed the way providers are reimbursed by inserting quality measures as a requirement for getting paid in full for services. It’s paramount to recognize the importance of accurate documentation and coding in this new reimbursement model since many payment models rely on accurate and timely documentation and coding.

The accurate capture of quality and patient risk factors is foundational to the success of value-based care programs. For example, the penalties for hospital-acquired conditions — which demand an accurate capture of patient conditions at the time of admission — can be costly and potentially avoidable with a successful program that includes education audits for physicians.

For payer trends, we’re seeing a lot more utilization review or medical necessity denials. Denials related to site of service and level of care are also increasing.

A way to avoid these types of denials is to ensure that you have clear and concise documentation. It's essential that the case management, clinical documentation improvement (CDI) and coding teams work closely together within the revenue integrity space.

Automation and technology are also very important throughout the patient care experience, all the way through post-discharge. This is key whether we’re working with short-stay admissions or addressing issues pertaining to the Two-Midnight Rule for Medicare.

Regulatory trends also impact revenue integrity. One of the big ones is the Medicare Inpatient Only (IPO) list, which identifies procedures that must be performed in the inpatient setting to qualify for Medicare coverage and payment. The IPO list was supposed to phase out gradually, but in the 2022 OPPS Final Rule, Medicare paused that plan.

As a result, hospitals and medical centers still need to ensure their medical necessity and CDI processes not only accurately capture and relate clinical risk factors, but also account for conditions on this IPO list. If IPO list cases are miscategorized as outpatient, the provider will suffer negative revenue impact.

Another recent regulatory trend, which began in January of 2021, is the movement of evaluation and management (E/M) determination from the traditional time-based approach to a more complex medical decision-making (MDM) approach.

We've seen a lot of providers transition to the more complex MDM program, but this does require a lot more thought and more detailed documentation. The transition to MDM also requires providers to be educated in the methodology, especially those accustomed to using only the time-based approach to determine their E/M.

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How should health systems prepare or adjust their revenue integrity strategy to address these models?

They should evaluate their revenue integrity program to understand any gaps. This should include an assessment of their revenue integrity structure, including policies and procedures governing the program and technology assessments.

They should then build short-term and long-term strategies that will cover people, processes and technology.

What are the top three challenges when trying to achieve superior revenue integrity? And how should they be addressed?

The first challenge is finding talent and staffing a revenue integrity program. Revenue integrity as a discipline is a fairly new concept, and it isn’t easy to find people with the appropriate skills. One possible solution to that challenge is engaging a strategic outsourcing partner to provide seasoned staff. Typically, partners also bring technology and best practices that help you make the most of your talent.

The second challenge is the state of constantly changing payer requirements. A good way to address this challenge is by ensuring your technology is kept up to date. That includes your electronic health records system and all its associated and supporting technologies. You really want the latest technology built into your workflows before claims go out so you can maximize the chances they are paid appropriately instead of being denied.

Finally, health systems face a constantly shifting regulatory environment. I’ve worked in health care for a long time, and the regulations have always been constantly changing. Again, agile technology supported by people who understand those regulatory updates can help.

Can you explain how a holistic revenue cycle management approach, rather than piecemeal, might be better for improving revenue integrity?

Initially, many health care organizations focused on CDI, utilization review and CDM maintenance in a vacuum. Now, revenue integrity also includes charge capture, coding and even appeals. There are a lot of gaps between those solutions. A holistic revenue cycle management approach bridges those gaps between clinical operations, coding, CDI and the business office.

With a comprehensive approach, you can introduce more checks further upstream to catch problems before it’s too late. The results are a revenue integrity program with better coding and charge capture, reduced risk of noncompliance, optimized payment and reduced expenses from not having to fix problems downstream with claim edits or eventual denials.

What practical benefit does technology — including intelligent automation — contribute to fixing or improving revenue integrity? Can you give some examples?

Technology can be quite beneficial for improving revenue integrity. One example would be CDI tools that provide automated queries, prioritized worklists and improved outcomes.

Computer-assisted coding products are another example. Having them both on the same platform is powerful since better communication between CDI and coding helps to simplify and improve both functions.

Claims workflows and logic can also continually review and update edits and holds and automatically assign work to the appropriate team member. Often, manual edits get routed to the wrong team. It’s vital that those edits are handled by folks with the appropriate knowledge and certifications. Technology really helps here.

Additionally, certain technology, particularly artificial intelligence, can do a first pass at utilization review for patient status decisions and provide support for those decisions. That can save time and make medical necessity decisions more defensible.

Another huge benefit is that artificial intelligence can help case managers focus on the cases that need their attention, freeing up time they can spend on other top-of-license responsibilities.

Providers will want to ensure that whatever technology they use is embedded in their workflows and that everyone uses it. Inconsistency is your enemy. Only when analytics has a comprehensive view of the process can it meaningfully identify areas of improvement.

How are workforce shortages impacting revenue integrity, and how should organizations address this problem?

Staffing has been a challenge for some time, and the baby boomer bulge suggests it isn’t going away any time soon. The skillset and experience for revenue integrity were scarce and unique even before COVID-19, and “The Great Resignation” has only made things worse.

There are some steps you can take to help alleviate workforce challenges. The first is to cultivate talent within your organization, particularly among coding and patient financial services teams.

Secondly, look to strategic outsourcing partners. These relationships offer access to national resources beyond your immediate area, and to innovation and technology to close the gap between the staff you need and the employees you have. Staffing agencies can help, but they’re a Band-Aid to get through the short-term and not really a viable long-term option.

Ultimately, organizations need an intentional approach to get the most out of their revenue cycle staff. Solicit buy-in from your key stakeholders. Set up strong policies and procedures and assign resources that support them. Identify areas where automation can help increase efficiency. And, critically, identify what analytics to perform and have a plan to report out on every function to identify areas that will need improvement.

Don’t be afraid to engage consultants. No two programs are alike, and industry experts can help you build a program to meet your unique goals.


About Renee Monahan, Senior Director, Optum Advisory Services

Renee Monahan has more than 25 years of experience in health care revenue cycle and reimbursement, and currently serves in the Optum Advisory Services Revenue Cycle Consulting Practice. Her areas of expertise include revenue cycle KPIs and benchmarking, revenue integrity strategy, denials management and accounts receivable valuation modeling.

She holds a bachelor’s degree in accounting and an MBA from Saint Francis University.

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