Case study: A revenue integrity success story 

Nearly $32 million in savings from charge capture improvements. Another $11.6 million in savings from optimizing denials management. Expanded revenue cycle improvement capacity by five full-time equivalent positions. 

One five-hospital health system achieved all this. But how? 

By optimizing its revenue integrity operations. The following case study reveals how the system did it. 

Optimizing revenue integrity: Key steps taken 

First, a quick definition: What is revenue integrity in healthcare? 

It’s the discipline through which healthcare organizations monitor how well their end-to-end revenue cycle management processes function. Revenue integrity, whether performed by a dedicated department or individual, continuously checks for systematic gaps, problems, and deviations from established performance standards in revenue cycle processes and addresses them. It’s a vital function that plays an integral role in improving cash flow and net revenue performance. 

The five-hospital system sought out Kodiak for assistance in improving gaps in two areas critical to revenue cycle performance: charge capture and denials management. 

Specific steps taken included the following: 

Charge capture improvements 

Kodiak helped the health system establish best practice workflows within its clinical and charge entry departments. The workflows were aimed at driving improved and compliant revenue capture, particularly in three clinical service lines that were determined to need the most help: emergency department, observation services, and interventional radiology/invasive cardiology. The health system made improvements in four main areas: clinical, health information management/coding, reporting and monitoring, and revenue integrity support. 

Clinical 

• Introduced improvements within Epic, the health system’s EHR system, including building out nursing documentation best practice advisories (alerts within the EHR) and physician documentation templates. 
• Created charge-by documentation for certain procedures. 
• Optimized facility-ED-level criteria within the EHR system. 
• Conducted education for nursing staff about EHR changes, including messaging about crucial documentation elements and how they drive revenue. 
• Built educational materials into the health system’s onboarding education program to make sure knowledge isn’t lost with nursing turnover. 
• Built out charge and reconciliation processes within each service line and clearly delineated ownership of the overall process to the revenue integrity team. 

HIM/coding 

• Conducted education on coding rules to ensure documentation is made in the right place within the EHR system and that charges and codes are captured appropriately. 
• Reviewed and updated charging and coding policies to make sure they accurately reflect updated coding guidelines and regulations, e.g., Centers for Medicare & Medicaid services coding guidelines. 
• Implemented a quality assurance program and recommended ongoing reviews be conducted to monitor performance across all service lines. 

Reporting and monitoring 

• Built out operational reports within the health system’s EHR system, including a missing stop time report that allows clinical department leaders to monitor compliant medication administration documentation in real time and make edits before a patient is discharged. 
• Used the organization’s charge and claim data to compare its current performance against its historic baseline and against comparative market key performance indicators. 
• Built Revenue Guardian edits within the EHR system to help protect against revenue leakage and identify accounts that might be missing high-dollar supplies, implants, and/or procedures. 
• Made several improvements related to availability and accessibility of data, including: 
• Determining how operational leaders want to receive and interpret various reports so they can be presented in the most useful format. 
• Building dashboards for the revenue integrity team and training them on how to input new data on an ongoing basis and on how to use the different tools to get the most benefit. 

Revenue integrity support 

• Aligned the revenue integrity team with service lines. 
• Identified “charge champions” to reinforce service-line ownership and foster relationships across key stakeholder groups. The charge champions now: 
• Help guide the organization’s charge reconciliation processes. 
• Initiate processes for new services and supplies. 
• Help educate clinical and charge capture personnel. 
• Manage work queues. 
• Monitor reporting and develop action plans when net revenue performance is found to be below established thresholds. 
• Fostered a partnership between the revenue integrity team and clinical leadership to ensure effective communication pathways are in place to address future revenue issues or concerns. 
• Redesigned revenue integrity functions and built out revenue integrity specialist roles, redefining responsibilities and expectations. 

Denials management improvements 

Working with the health system, the Kodiak team focused on improving work queues and staff education related to claim denials. Improvements made in this space included: 

• Developed work queue scoring principles focused on each account’s value. By prioritizing high-value accounts, the health system increased cash collections. The team now focuses on the most valuable accounts based on: 
• Expected reimbursement, determined by higher balances. 
• Risk, especially relating to timely denial/appeal deadlines by payor. Accounts nearing timely filing or appeal deadlines are now prioritized to reduce denial write-offs. 
• Age, meaning, if all else is equal with balance and risk, older accounts are to be worked first. 

The results 

In addition to the optimized charge capture and denials management work, fundamental structural changes were made to the health system’s revenue integrity team that generate benefits today. 

For example, Kodiak helped the health system centralize its revenue integrity function and streamline operations. After conducting a staffing analysis and modifying rules, responsibilities, and job descriptions for the revenue integrity team, Kodiak determined the health system could bring in an additional five FTEs to fill gaps in skill sets, experience, and knowledge necessary for a high-functioning, highly successful revenue integrity team. 

Kodiak also worked with the health system to develop communication and education programs for the revenue integrity team and charge champions. These programs will help ensure staff have the resources they need for success going forward. 

In all, this work brought in more than $43 million for the health system while setting the organization up for continued financial and operational success thanks to a revamped, high-functioning revenue integrity department. 

How is your revenue integrity? 

Lack of a robust revenue integrity program can result in significant financial exposure for your organization, due to factors like inability to capture missed charges, increased denials, and even audit penalties. As demonstrated in this case study, a high-functioning revenue integrity process can help stop revenue leakage on the front end and reduce an organization’s administration burden. 

Kodiak has worked with many healthcare organizations to turn around their revenue integrity programs. Contact us today to find out how we can help you.