Revenue Integrity: A more holistic view of healthcare finances

Thinking of the patient experience first and breaking down traditional siloes between departments can help healthcare organizations deliver more human-centered revenue cycle management.

By and Kelsey Clements | 3 minute read | November 16, 2020

A case management executive once said, “I’m not sure why I’m here. I don’t do anything with revenue cycle.” We were just beginning an engagement to help a healthcare organization improve its revenue cycle performance and had gathered leaders from different disciplines together to kick off the project. As the session continued, and we shared ways in which case management and utilization review have a significant impact on denials, she understood just how critical her participation was.

Her reaction is not an uncommon perception of revenue cycle performance, which has taken center stage as hospitals are increasingly under tremendous financial pressure. Recent reports characterize the challenges of COVID-19 on hospital finances as “catastrophic,” with estimated losses of $202.6 billion over a four-month period for American hospitals and health systems.1

When focusing on three key areas to find more money for their mission, healthcare organizations look to reduce bad debt, reduce denials and streamline accounts receivable management. These tasks are traditionally thought of as “claims management” activities, relegated to the billing office.

But healthcare organizations that take a more holistic, human-centered approach to revenue cycle management will be more likely to achieve their goals. This approach can help them focus on revenue integrity, which means they apply comprehensive and well-defined goals, processes and metrics to become more efficient and earn optimal, accurate reimbursement.

Taking a human-centered approach for revenue integrity

Like any business, healthcare organizations must examine the products and services they deliver and determine an appropriate cost structure that translates into revenue. To achieve revenue integrity, they must think holistically about the experience they want to provide.

A human-centered approach to this task will have many facets, reflecting two main priorities:

1) Put the patient first.

The revenue cycle is a cumulative process that follows the patient; wherever the patient goes, the revenue process follows. The patient’s experience begins long before arriving at a physical location. Even before the visit or service, there are key processes – such as collecting demographics, eligibility checking and prior authorization – that impact how these services are paid downstream. If not done properly, they can affect the patient experience.

For example, imagine a patient arriving at the hospital for a critical surgery. As she anxiously makes her way through pre-op, someone from financial services asks her to sign a document accepting financial responsibility for all services, because the pre-authorization step is not complete. This is just one example of how a broken step in the revenue cycle management process can negatively affect patient experience.

2) Make it easy for teams to collaborate and solve problems.

Healthcare organizations should bring together multiple functions to help them understand their connectedness, and how their work influences the revenue cycle.

For example, a patient has a visit at his physician’s office that requires additional follow up. Is there an order? Is there an accurate diagnosis? These components translate to medical necessity, which is fundamental to a successful claim. The next opportunity to review the claim is in scheduling, where they can address any missing information. Next, the claim may move to financial counseling, verification, authorization and so on. But if no one addresses mistakes – especially those that are recurring – claims will continue to be defective, and someone, somewhere will need to fix them to obtain earned revenue.

Each team member will come with a different perspective, depending on where they are involved with the process. Team members should have the opportunities, tools and techniques that help them raise challenges and work on them collaboratively to improve processes.

Revenue integrity is more than a clean claims rate. To achieve revenue integrity, organizations must have a comprehensive revenue cycle management strategy that keeps people – both patients and employees – as priority number one.

  1. American Hospital Association Guide: Hospitals and Health Systems Face Unprecedented Financial Pressures Due to COVID-19, May 2020.