The concept of revenue integrity holds contrasting-but-compatible views on the same subject: One lens is a micro view of the little details while the other lens is a macro view of the landscape. Together, they form a panoramic picture showing an end-to-end revenue cycle with all the pixilated points along the way. At least that is the financial community's vision of it.
Essentially, "revenue integrity" is a new buzz term for rethinking revenue cycle management, said Greer Contreras, vice president of revenue cycle coding for Dallas-based T-System.
"It revolves around the revenue cycle process but refers to a different way of looking at it in complex financial times," she said. "By adding 'integrity,' you are taking a holistic approach - another viewpoint to make sure pieces aren't falling off. Organizations have struggled a bit because the revenue cycle is often isolated and compartmentalized. They need to look at it as one piece."
Revenue integrity also consists of taking a close-up view of revenue cycle components. Depending on which and how many services are rendered, patient charges can take a long and convoluted path on the way to becoming a finished invoice. Without a fastidious system that uses data capture technology and seamless transference of patient insurance status, allowables, deductibles and co-payment information, healthcare providers can be losing serious amounts of money that is due to them, Contreras said.
"Financial leaders need to take a start-to-finish look at departmental deficiencies and the integrity of the entire cycle," she said. "It begins with getting the correct information at intake and diligence throughout the process until it reaches the back end."
Taylor Moorehead, partner for Carmel, Ind.-based Zotec Partners' west region, added that revenue integrity should ensure the value of every contracted service.
"If you have an agreement to receive $1,800 for every knee replacement surgery, revenue integrity means that you should be getting that amount every time," he said.
'Blur the divide'
Along with providing a clear information pathway, revenue integrity also stands for compliance, said Steve Everest, executive vice president of financial solutions for Houston-based Prognosis Health Information Systems.
"It means adhering to billing regulations, reporting standards and instituting efficiencies for sending information through the revenue cycle system while maximizing reimbursement for services provided," he said.
Prognosis specializes in serving small community hospitals, which collectively face greater financial and technological challenges than their "big city cousins," Everest said. As connectivity has advanced, he said, so have opportunities to improve revenues.
"They are trying to get better," Everest said. "Instead of laying everything on the back office to sort out after the fact, we're helping them blend the information upfront - getting both the financial and clinical groups to blur the divide. We're teaching our clients to address these things as they happen and head off a mess at the end."
Revenue integrity is more than a term - it is a revenue model itself, said Kevin Arner, CEO of Jacksonville, Fla.-based PaySpan.
"Revenue has traditionally been an afterthought, but it is not something we can continue to manage in that way," he said. "It should begin at the onset of care and requires conversation on the functional capabilities of providers and a dialogue with payers. It should consist of integrating processes across the entire revenue life cycle. The old way doesn't really support the downstream business process that drives reimbursement."
The clinical community, to its credit, has evolved significantly in the quest to capture data at the point of care, said Arner.
"They've taken a big step forward and have done well with the capture," he said. "What hasn't adapted are the financial tools to support the process. They have been antiquated. Patient interactions are different than payer interactions."
Eyeing the middle
Rob Jones, director of revenue enhancement practice for Chadds Ford, Pa.-based IMA Consulting, believes that great attention has been placed on the front and back ends while the largest segment - the middle - gets neglected.
"These are the aspects of coding and compliance - all the dots in the continuum of care within the revenue cycle need to be connected," he said. "We've relied on technology to push information from front to back, but the challenge is only as good as the people who program it and if it is not programmed by experts, there will be gaps. The emphasis is to focus on systems and people so that everyone involved truly understands the complexity from beginning to end."
The claim form may be the most important document in the entire process, Jones said, because it is the catalyst for getting revenue in the door. The form is structured to capture a comprehensive data profile that puts the entire revenue cycle in motion, he said.
"By the time it hits the business office, the staff should be working on getting that claim paid," said Jones. "This is a process with no short cuts - it should include everyone, from front to back."