What is healthcare revenue integrity?

By at least one account, the annual healthcare revenue cycle market is worth more than $61 billion and will grow to more than $105 billion by 2030. Hospitals, health systems, medical practices, and others are spending a lot of money to get paid for rendering medical care and other healthcare services to patients. Whether they get paid accurately, fairly, and on time depends on revenue integrity.  

This thought leadership article explains what revenue integrity is at a high-level, where revenue integrity lives along the revenue cycle management continuum, and why doing it well improves both revenue cycle performance and net revenue results for providers.  

What is revenue integrity in healthcare? 

Revenue integrity is the discipline through which a healthcare organizations monitors how well all of its end-to-end revenue cycle management processes are functioning. Think of revenue integrity as quality assurance or quality control for the entire revenue cycle. Revenue integrity continuously checks for systematic gaps, problems, and deviations from established performance standards in an revenue cycle process and addresses them. 

What is the goal of healthcare revenue integrity? 

The goal of healthcare revenue integrity is to ensure that healthcare organizations are accurately, efficiently, and compliantly capturing and reimbursed for the clinical services they provide. It serves as a critical quality assurance function within the revenue cycle, aiming to: 

• Prevent revenue leakage 
• Ensure regulatory compliance 
• Improve financial performance 
• Strengthen operational efficiency 
• Support complete and accurate clinical documentation 
• Cultivate interdepartmental collaboration  

Who performs healthcare revenue integrity? 

Not all healthcare organizations have a revenue integrity discipline along their revenue cycle management continuum. Those organizations that do, do it differently.  

In our work experience with hospitals, health systems, and medical practices, we’ve seen revenue integrity models in which:  

• One person is solely responsible for revenue integrity functions 
• A team of people is responsible for revenue integrity functions 
• Revenue integrity is embedded into the job descriptions of managers who oversee each distinct part of the revenue cycle management continuum 
• Some may not always have all the functions under the revenue integrity umbrella that are part of leading practice 

Regardless of the model, having a revenue integrity discipline integrated somewhere into the revenue cycle management continuum is essential for ensuring accurate reimbursement, maintaining compliance, and preserving the financial health of the organization.  

Where does revenue integrity sit along the revenue cycle management continuum? 

The healthcare revenue cycle management continuum is divided into three parts: front end, middle, and back end. The three parts of the healthcare revenue cycle management continuum generally correspond with three parts of a patient’s typical episode of care: before care is rendered, while care is rendered, and after care is rendered.  

The revenue integrity discipline lives in the middle phase of the healthcare revenue cycle management continuum, or the period during which patients are receiving care and that care is charge captured.  

By continuously monitoring for systematic gaps, problems, and deviations from established performance standards in the revenue cycle processes that live in the middle of the healthcare revenue cycle continuum, revenue integrity ultimately improves performance of the revenue cycle processes that reside in the front and back ends of the revenue cycle. In short, it makes each end better. 

What revenue cycle processes live in the middle of the healthcare revenue cycle continuum? 

Revenue integrity typically monitors, or audits, the performance of the following revenue cycle processes that sit in the middle of the healthcare revenue cycle management continuum: 

• Hospital and clinic charge description master 
• Pricing strategy 
• Charge capture training and auditing 
• Clinical documentation improvement 
• Health information management and coding 
• Utilization review and case management  
• Denials prevention and management 
• Managed care/contract management 
• Payment variance 
• Analytics and reporting (e.g., revenue monitoring, charge reconciliation) 

It’s a long list of processes, each with its own unique set of performance standards. Revenue integrity is responsible for quality assurance and quality control in meeting those performance standards for each of those processes. Revenue integrity is also responsible for ensuring that all those processes are working efficiently, seamlessly, and in harmony with each other and with both the front and back ends of the revenue cycle management continuum.  

What are some common gaps in middle revenue cycle processes that revenue integrity oversees and addresses? 

Continuous change drives the daily life of whoever is in charge of revenue integrity at a hospital, health system, or medical practice. Revenue integrity professionals manage a wide range of middle revenue cycle processes on a daily basis, including but not limited to: 

Charge description master 

There typically are more than 15,000 billable services listed in a hospital’s charge description master. The hospital’s list of billable services changes often, as does how much it charges for each billable service.  

A hospital’s CDM is buffeted by a steady flow of regulatory and market dynamics, which shake up that list constantly. State and federal price transparency rules, regulations, and requirements. Mergers, acquisitions, and partnerships that change the competitive dynamics of a market. New market entrants from non-traditional healthcare companies. Payor mix and managed care contracts. Supplies and implants. Pharmaceuticals. New medical techniques and technologies. Strategic pricing initiatives. They all come together to make a hospital’s CDM a living, breathing file.  

It’s revenue integrity’s job to monitor the CDM to ensure it’s up to date at any point in time and that everything and everyone connected to the CDM is up to date on all changes.  

Charge capture and clinical documentation integrity (CDI) 

Every billable service provided to a patient during their episode of care must be accurately documented in the medical record. Clinical documentation not only supports the care that was delivered but also serves as the foundation for billing and reimbursement. Charge capture is the process by which providers document and record all services, procedures, and supplies provided to the patient. It ensures that clinical documentation supports each billable service. Both charge capture and CDI are core functions within the middle revenue cycle – the bridge between clinical care and financial reimbursement.  

What makes revenue integrity monitoring challenging are payors’ ever-changing clinical documentation and billing requirements. Payors may strengthen, loosen, eliminate, or add documentation and billing requirements with each contract or with each service. Payors may formally notify a provider of a change in a requirements—or not. Payors may not consistently apply document and billing requirements to the same diagnoses or treatments.  

It's revenue integrity’s job to ensure that the CDI process is functioning properly by ensuring provider documentation is accurate and complete, and all clinical documentation and billing requirements from payors are being met. 

Coding  

It’s said for every season there is a purpose. For revenue integrity, it’s said for every billable service there is a billing code. Thousands of them.  

For example, there are about 55,000 ICD-11 (11th version of the International Classification of Diseases) codes. Providers assign an ICD-11 code to a patient’s disease, disorder, injury, or cause of death. Also, there are more than 11,000 CPT (Current Procedural Terminology) codes. Providers assign a CPT code to a service performed by a medical professional, whether that’s medical, surgical, or diagnostic. 

Providers must map all those codes accurately to the right disease, disorder, injury, cause of death, or service. Providers use those codes to bill for services rendered. Clinical documentation must support all codes used. In other words, you must show your homework to a payor. You have to justify the code you’re using to bill for payment.  

It's revenue integrity’s job to keep all code sets up to date, keep all code sets mapped to the right things, and to ensure coders are assigning the right codes to the right things the right way. Any gap or misfire in coding can lead to a denied or delayed claim because it wasn’t clean.  

Ultimately, the revenue integrity discipline is to consistently submit what’s often referred to as a “clean claim” to a payor for billable services provided to a patient during an episode of care. A clean claim is the result of a high-performing revenue integrity function that: 

• Captures all billable services provided to the patient. 
• Supports the services provided with accurate and complete clinical documentation. 
• Follows the patient’s health insurance rules for submission for payment. 
• Adheres to the patient’s health insurance benefits. 
• Is coded correctly with the right billing codes. 
• Reflects accurate and up-to-date fees and charges for services rendered. 
• Is billed to the payor as quickly as possible after an episode of care ends. 

Submitting a clean claim to a payor for payment greatly increases the chance that the payor will pay the claim accurately, fairly, and on time, improving the provider’s cash flow and net revenue performance.  

However, revenue integrity’s responsibilities extend beyond claim submission. Once a claim is sent, the team actively monitors for denials, addresses them appropriately, and ensures that reimbursements from payors are accurate and complete. 

Conclusion 

Revenue integrity’s role in the healthcare revenue cycle process is complex, complicated, and ever-changing. Mastering revenue cycle can be challenging. But mastering revenue integrity is the secret to improving cash flow and net revenue performance for hospitals, health systems, and medical practices. Effective revenue integrity generates clean claims that lead to accurate, fair, and prompt payments for services rendered from payors.