A Guide To Revenue Integrity Solutions In Healthcare

Even as the world gears up for the third year of the COVID-19 epidemic, its effects can be seen in every aspect of healthcare. Health information (HI) workers face a variety of difficulties connected to the complexities of information release in meeting demands for patient data sharing and interoperability (ROI).

In order to justify more complicated care, such as telehealth, telemedicine, and psychiatric care, medical record demands have increased significantly.

Revenue Integrity: What Does It Mean?

In healthcare, revenue integrity is the technique of converting patient experiences into money and minimizing revenue leakage or compliance difficulties. It’s no longer just about “revenue optimization” but rather about “revenue integrity,” which also encompasses contractual and legal compliance. Your revenue management cycle includes several different aspects of revenue integrity.

The integrity of income can be established and maintained by using people, procedures, and platforms. You can prevent income leakage by uncovering revenue integrity issues before they become a problem.

As per the National Association of Healthcare Revenue Integrity (NAHRI), the goal of revenue integrity is to prevent recurring problems that could lead to revenue leakage and/or compliance risks. To achieve this, organizations must implement processes and controls that are effective, efficient, replicable, and supported by appropriate documentation and sound financial practices that can withstand audits at any time.

Imagine revenue integrity as a bridge that connects clinical, coding, & revenue cycle processes, resulting in enhanced workflows and more revenue. Your hospital’s revenue integrity will improve as soon as you begin implementing processes, employing reliable platforms, and placing the correct people in charge.

Analyze The Expense And Resources

Assessing communication strategies, actual expenses, employee time, and resources is critical to supporting revenue retention.

Electronic Communication vs. Paper Delivery – For businesses, electronic communication is preferred over paper delivery since it ensures secure file transfer between the payer and the

organization. Although paper is still the most used distribution method, electronic is the future.

Cost to Process – Start with the actual printing and shipping costs—paper, toner, and postal supplies—to get a basic idea of the total cost of processing. How much does it cost to have this process in place? Is there a turnaround time for delivering records to payers? We need to know how much of a financial impact this has had on the company.

Shipment of Paper – The payer should be held responsible for the prompt receipt of claims and medical documents. Even certified mail with tracking has become less trustworthy over the past year. Because of high page counts and a decrease in on-site staff, payers have rejected shipments. Consider certified, priority, or FedEx delivery options. Calculate the cost of each shipping service and hold the payment responsible if the shipment is not received or refused.

Amounts of Time and Money – Consider the time required by the staff to complete a medical release, including the time spent waiting for it to be processed (non-value added). Be sure to account for the time it takes to print, package and mail medical records, including the time it takes to make necessary updates to the patient financial services system and wait for payment.

Remote work methods have impacted COVID-19’s processing times. Build-in wait time if medical records are only printed once a week and sent out that way. Remember that records are printed every Friday and delivered the following Wednesday. That translates to a five-day lag for accounts to age.

FTE Costs to Process – Calculate FTE expenses, including salaries and wages, time spent processing, time unavailable to process claims or handle other value-added tasks, and wait time.

Technology Can Aid In Achieving Revenue Integrity Objectives

Technology can play a critical role in ensuring that their revenue integrity targets are being met. Employees can spend more time with patients by using automated RCM solutions.

Automated coding analysis can help to reduce claim denials by allowing personnel to review coding before filing claims.

It’s easier to identify potential problems with Medicare billing and follow-up with the help of fully autonomous Medicare reporting and analytics. Checking your eligibility in real-time from the Medicare system can also assist you in resolving reimbursement concerns before they arise.

You may even improve the integrity of your company’s revenue by cleaning up its financial records with the correct tools. Likely, your hospital’s revenue cycle is not running smoothly if it has a series of transfer DRG-related underpayments.

Common Issues with Revenue Integrity

Expired and Delayed Payments

There are more than a few steps involved in charging. Contracts, deductibles, treatments, and paperwork must be sorted out before insurance coverage can be established. Missing or delayed charges might result in revenue loss due to a variety of circumstances. Charge inconsistencies between clinical and billing are a major source of revenue loss.

A hospital is making a loss if physician charges are not properly tracked. Developing a scientifically based billing system is critical for any hospital that wants to take responsibility for its revenue cycle management.

Compliance Adherence

The requirement for more exact coding and charge capture arose as a result of Medicare’s addition of hierarchical condition categories (HCCs) for the risk assessment of patients. Healthcare systems must abide by all applicable state and federal laws and regulations.

HIPAA, SOC I & II, and the Price Transparency Mandate are just a few rules that must be followed. To ensure price transparency, compliance, and significant revenue integrity in a healthcare company, it is essential to maintain track of legislation and obligations.


When it comes to healthcare, most patients don’t have to pay for everything out of cash. As a result, a complex healthcare payer network is created through insurance contracts.

Medical billing offices receive a record of the money that has been deposited directly into their bank accounts from insurance companies. Because the deposit doesn’t always reflect the record, it takes a lot of time and money to correct the error.

Denial Rate

When a payer denies a claim, it may indicate that there are issues with the coding, charging, or billing process or that there are problems with the contracting process. Claim denial patterns can be used to improve the workflows that lead to submission problems, which in turn can lead to a surge in revenue.

Keep an eye on the percentage of denied claims as well as the money amounts. There is a standard denial rate in the sector of 5% to 10%, with only 2% to 3% deemed to be effective.

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