Revenue Integrity & Capture – Who’s Herding the Cats?

Cross functional processes can be difficult to manage in hospitals. One reason pertinent to Revenue Integrity is that typically, the organization structure is a series of vertical disciplines with differently defined focus (HIM, PFS, PATIENT ACCESS, ANCILLARY DEPARTMENTS, MD’s, et.al.). This structure can be and is very effective in many hospitals. However, revenue integrity management doesn’t always “fit”. It requires that all of these disciplines (a) agree on work definition, (b) have consistent education addressing CDM changes, compliance matters and related topics, (c) have the tools in place to manage their performance (d) are clear on current state and change opportunities that require attention (e) communicate routinely specifically about Revenue Integrity matters.

We all know the obvious – if revenue is not captured, coded and billed correctly we risk HIPAA violation consequences, cash flow, cost associated with denials and duplicate handling of work, patient satisfaction and P&L impact. So in an environment where cross functional processing challenges exist and the expressed risks are critical, “WHO’S HERDING THE CATS” in your organization to ascertain that you are banking every dollar that is coming to you? Who in your organization is charged to remain contemporary on what you can bill for and what you cannot bill for and related implementations as change occurs? Is that responsibility spread among various stakeholders and if so, do all disciplines in the revenue capture continuum agree or is there a need for conflict resolution – who identifies and handles that? Who is the leader?

Some hospitals have a staff position designated to lead the revenue integrity charge. In order to be effective, this role must be defined such that it carries authority that crosses organization lines. Other hospitals have established a committee or team consisting of representation from key stakeholders. The committee or team is usually lead by the CFO, VP Revenue Cycle or COO. Either structure or even some hybrid can be effective.

However, many hospitals have not embraced this field with a well-defined multidisciplinary plan that has a specific function as part of the organization. When we are asked to consult with those hospitals about revenue issues, it is usually because they are experiencing symptoms like inordinate denials, decline in same-store revenue, cash flow issues and sometimes conflict regarding coding policy. Our initial discovery work is designed to identify current state, confirm those “symptoms” and address what has caused them. As a result, we can introduce early wins and sometimes interim leadership but the more strategic solution often requires organization change that establishes Revenue Integrity discipline and accountability. It is rewarding to facilitate and see transformation in Revenue Integrity practices at hospitals that previously focused more on symptoms than development of a strategic approach.

If you are working on charge capture, CDM or another component of Revenue Integrity and have questions or if you have in place relevant best practices you are willing to share, please post to this BLOG so that others can benefit. Our healthcare management consulting experts are always available to answer questions or assist you regardless of where you are on the path leading to Revenue Integrity.

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Posted By: nearterm-admin
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