As a healthcare provider, we understand that delivering patient care is your primary focus. To do this effectively, your team of professionals must have the right skills. Similarly, maintaining revenue integrity will consistently drive revenue.
Revenue integrity (RI) plays a crucial role when you’re trying to streamline your revenue cycle, however, you may ask what is revenue integrity in healthcare? It is a subjective term but in healthcare it refers to revenue generation through each patient encounter simultaneously maintaining compliance and avoiding any potential losses.
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As a healthcare provider, we understand that delivering patient care is your primary focus. To do this effectively, your team of professionals must have the right skills. Similarly, maintaining revenue integrity will consistently drive revenue.
Revenue integrity (RI) plays a crucial role when you’re trying to streamline your revenue cycle, however, you may ask what is revenue integrity in healthcare? It is a subjective term but in healthcare it refers to revenue generation through each patient encounter simultaneously maintaining compliance and avoiding any potential losses.
RI in Healthcare – Explained
Revenue integrity plays an important role in RCM operations where people, processes and platforms are key players. You can avoid revenue losses by identifying and resolving revenue integrity issues before every clinical encounter.
According to the National Association of Healthcare Revenue Integrity (NAHRI), revenue integrity’s goal “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 can withstand audits at any point in time.”
It is the bridge that helps connect all revenue cycle operations with clinical coding. It simultaneously boosts revenue and increases efficiency. You can optimize your revenue integrity by implementing processes aligned to your needs, appointing experienced and highly qualified people, and utilizing the right platforms.
An important step to ensure revenue integrity is to identify the issues that typically affect it.
Delayed or Missing Charges
As a process generating bills can be error prone thanks to the various processes it includes—paperwork, sorting contracts and calculating treatment costs. Errors in any of these steps can directly result in loss of revenue. In fact, such discrepancies and errors in medical coding are among the leading causes that negatively affect revenue cycles.
Compliance and Price Transparency
Healthcare providers must comply with federal regulations, including Health Insurance Portability and Accountability Act (HIPAA), Systems and Organization Control (SOC) I and II. Compliance helps maintain price transparency and revenue integrity.
Payment Discrepancy
In most cases, patients do not pay for services in full. Instead, insurance providers settle the balance directly with healthcare organizations. However, the payment record may not always be aligned with the actual deposit. It takes time and money to correct such discrepancies.
Examples of Revenue Leakage in Healthcare
Revenue leakage in a healthcare organization can happen in many ways. Let’s take a look at some examples.
Unpaid Amount
If we talk about healthcare, a real example of revenue leakage would be when billable amounts remain unpaid for long durations. It is believed that the more time it takes to follow up on a payment, the harder it becomes to retrieve the amount
Underpayment
It is common for disputes and misunderstandings to occur when transferring a contract from one insurer to another. Although underpayments are said to be better than claim denials, they still impact the revenue cycle of the organization
Claim Denials
Did you know that healthcare organizations permanently lose about 3% of their total net value to claim denials? They also have to spend a lot more money if they want to appeal a denied claim. This is why it is important to file properly documented claims in the first go to reduce denials.
Some other examples include unrepresented ICD-10 codes and bad debts that patients are unable to pay back.
Best Practices in Maintaining Revenue Integrity
Now that you’re familiar with the challenges, let’s take a quick look at some best practices that will help you avoid errors.
- Streamlining Processes: By optimizing the process with the help of expert coders and billers, organizations can decrease inaccuracies, discrepancies and enhance its revenue cycle management
- Regular Training: It helps update the employees with the latest regulations, technological advancements and compliance guidelines thus improving efficiency
- Regular Monitoring: Healthcare organizations can help improve their overall performance by regularly monitoring processes and optimizing them
Maintaining revenue integrity in healthcare requires specific skillsets at each step of the revenue cycle. We understand that hiring an experienced and credentialed team to help may not always be the solution. However, you could consider outsourcing to a reliable business partner like Valerion Health who will be empathetic to your everyday challenges.
Enriched by decades of industry experience, we can effectively assess and streamline your RI efforts. Our consultative approach is sure to result in solutions to optimize your operations.
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