By Susan Chapman for For the Record
Health care organizations are increasingly adopting revenue integrity (RI) programs, which, as defined by the National Association of Healthcare Revenue Integrity, are valuable to “prevent recurrence of issues that can cause revenue leakage and/or compliance risks through effective, efficient, replicable processes and internal controls across the continuum of patient care, supported by the appropriate documentation and the application of sound financial practices that are able to withstand audits at any point in time.”
In essence, RI helps ensure an organization’s revenue performance, which is necessary to support optimal patient care and quality outcomes, closing gaps that can impede correct reimbursement.
The Healthcare Financial Management Association reports that the field of RI began to emerge in 2004 “as health systems moved toward value-based and risk-adjusted payment models. When Medicare added hierarchical condition categories to assess patient risk as part of the consideration for payment, the need to be precise with coding and charge capture increased.”
“RI is a relatively new term,” says Betsy Weiss, RN, MPH, director of revenue cycle at St. Francis Medical Center in Trenton, New Jersey. “Our hospital is a community-based teaching hospital. When I began here 12 years ago, my position was ‘insurance auditor’ and the focus was billing compliance. At that time, the role was to ensure that the claims went out clean, and I functioned as a liaison between billing and the clinical side. The concept of RI evolved over the years and has become more robust. Not only do you want to ensure that your claims are going out clean, you also want to make sure your revenue capture is correct. RI can be highly variable between organizations and, even within the same organization, there can be various RI teams addressing different facets of the revenue cycle. We’re not billers or coders, but we work together closely to make sure everything aligns.”
To illustrate RI, take the case of a physician ordering a 2-D echocardiogram. “Through documentation in the record, you can prove that a patient had that test. However, within the system there is a lot going on behind the scenes, including the way the order and charge appear in the electronic record and the way the codes are set up in the charge description master [CDM],” Weiss says. “All must align accordingly to ensure the charge is being captured correctly on the claim. The record must contain key elements, including the order, results, and any authorization information that could support the charges if a question were to arise.”
Christine Poleon, director of business analytics and intelligence, revenue cycle solutions, at AMN Healthcare, says RI plays a key role across the care continuum. “RI is important on the patient care side and it’s equally important to have on the operational side. The way the claim is produced, the integrity of the patient record—there is constantly a link to the care that is provided. When it comes to getting that claim out the door to the payer, there is the sense that it is defensible and clean, done through a collaborative approach among all caregivers. We like to think of it as a holistic approach, a nonsiloed concept that requires participation from all providers across the health care continuum,” she says.
Establishing an RI Program
Poleon believes that when it comes to creating an RI program, there are two concepts: theory and reality.
“In theory, it’s a very collaborative model, across all departments, that creates the correct reimbursement. In reality, we see there are critical departments that tend to get overlooked because they’re viewed as less operational than clinical in nature,” Poleon says. “If you’re going to create a program, try to steer away from what your counterparts are doing because they may not have created the ideal model. Understand your unique organization and start it right from the very beginning.”
“A good starting point is with the CDM,” Weiss says. “Most hospitals have someone that manages the CDM, the backbone of your whole financial system. At our hospital, it is the foundation of the RI program. The management of the CDM personnel often falls within the finance department and can vary from hospital to hospital. Their background can be in accounting, finance, IT, coding, or nursing. My team approaches it from the clinical perspective. Even if the CDM personnel have a business background, it is good to have someone with the clinical perspective on the team, someone who can audit medical records, communicate with the clinical leaders, and who understands the clinical delivery of care, like an RN.”
“A very important step is to identify all the stakeholders in the RI chain. Overlooking those critical stakeholders will result in a less-than-ideal outcome,” notes Daniel Land, RHIA, CCS, director of organizational learning, revenue cycle solutions at AMN Healthcare. “Look closely at the journey of the patient through the revenue-generating departments within a facility. Gain an understanding of how the departments relate to each other, how they impact a patient, and how they impact RI as a whole. There are certain departments within health care organizations that are not classified as direct revenue generating but can have tremendous impact on RI, such as HIM and coding.”
Poleon agrees that understanding the journey of the patient is important, adding that the process begins even before a patient enters the facility, a theory she believes to be particularly accurate in trauma and scheduled surgery cases. “Think of trauma and trauma-activation fees. The patient enters the emergency department and the life cycle begins even before the patient is treated. Such things as patient registration, duties the nurses perform before the patient is seen by a physician—those are all part of the life cycle. In scheduled surgery, the patient must have authorization and tests, and the person likely hasn’t even entered the facility yet. If the status of that patient isn’t right and timely from the very beginning, the RI breaks down immediately,” she says.
According to Poleon, in order for an RI program to be effective and successful, it must include these key stakeholders: patient registration personnel, caregivers, and clinical documentation specialists. “Patient registration is important because if they get the payer wrong, there is a breakdown in the RI. If caregivers miss documentation elements during patient care in the ED, then that documentation might have elevated that patient to a different status. And clinical documentation stakeholders can include HIM and/or case management. RI involves the whole utilization management team,” she says.
From an RI perspective, Land believes that documentation can be described as the foundation of the patient’s story. “From documentation flows coding, reimbursement, continuation of care, research, statistics, and many other activities. Documentation is one of the most critical pieces of RI. Without quality documentation, one cannot have RI,” he says.
When creating RI programs, Poleon notes that it’s important to start from a baseline and analyze where there may be potential outliers. “We need to pay attention to both the front- and back-ends, really doing a root-cause analysis. If we have outliers, how does that outlier affect that RI? As we’re building an RI program, we have to take a careful examination at the beginning, in the program build; if we’re not on point now, how do we get there? Who is involved? Is it possibly HIM, coding, somewhere else along the chain?
“It could have been an issue on the front end, not necessarily the fault of the coder,” Poleon continues. “It could have been an issue with the status of the patient. What the caregiver deemed as medically necessary, the payer doesn’t agree with. Taking that deep dive, or examining the root cause, at a macro level, is very important, and doing it right from a program’s very beginning,” she explains.
Land adds, “HIM and coding are central to RI programs, yet HIM and coding are not technically classified as revenue-generating centers within health care institutions. It’s an interesting dichotomy.”
“But if the codes are incorrect, they go to the payer, the CDC, and the WHO,” Poleon says. “If you are trying to achieve RI, if there is a breakdown in any one of those areas, you got it wrong. Are you going to get it right every single time? No, but there are industry standards out there. There is a 95% accuracy rate that is the industry standard, and not achieving that is not always the fault of the coder, which is often where blame can be placed. Everyone needs to understand that this is a top-down collaborative approach, and everyone should try to be on point.”
Weiss believes that an effective RI program is indeed collaborative, requiring close interaction with other departments and basing its success on strong relationships across the organization. “The revenue cycle is collaborative. We’re not working in a vacuum,” she says. “Members of the RI team are the troubleshooters. We exist in a connecting space, connecting with all the other departments, and they can bounce things off of us. We have to understand all the different system interfaces and have an understanding of all the departments to do our job well. Having a broader view of all the different pieces of the puzzle enables us to redirect issues to the correct departments for resolution.”
St. Francis did not have an RI program in place when Weiss joined the organization. “It wasn’t even a term that we used, but it emerged as a meaningful way to describe the role. In my current position as the director of revenue cycle, which is part of the finance department, I oversee the CDM and RI, and the person who reports to me is an RN with an RI title. The CDM area is a logical fit for an organization’s RI program, and it would likely report to one of these departments: finance, corporate compliance, or revenue cycle,” she says.
Regardless of which role actually takes the lead in a facility’s RI program, Land believes that the individual, or individuals, must understand the macro-level global revenue cycle and be able to establish a clear vision, setting measurable overarching goals.
“But they should also understand the revenue cycle and RI on the micro level,” he says. “The leadership needs to identify all stakeholders, understand their unique links in the chain, clearly establish relationships among stakeholders, and stay abreast of all rules and regulations governing reimbursement. The mantra should be proactive, not reactive.”
“A coleadership situation would be ideal, where you have leadership representation of finance and also quality,” Poleon says. “If that isn’t possible within an organization, I would hope that a single leader can understand both sides—finance and quality—and all of the associated stakeholders and departments.”
Hurdles to a Successful Program
Lack of buy-in from key stakeholders can negatively impact an organization’s RI program, as can lack of collaboration. “If you have an organization that has a number of departments that don’t effectively talk with one another and don’t understand all the facets of health care, then you can have problems with your RI program. If there is a ‘we’ve always done it this way’ type of mentality, that can also be a big issue,” Poleon says.
Weiss agrees that buy-in is an important factor. “You have to have buy-in from all the stakeholders who may not immediately see the value in their world of what you are looking to achieve. You have to show people the reason you need to enlist their assistance and put it in terms they can understand. Resistance among people on the team can stand in the way of progress,” she notes.
Lack of resources can be another critical obstacle. “There is always so much more that can be done if you have the resources to do it,” Weiss explains. “You have to be open-minded when you lack certain resources and find a new or innovative way of doing it.”
Land concurs, saying, “I’ve heard the argument that we don’t have the resources—time, money, human capital—to create an RI program as some institutions are just trying to keep the lights on. But the truth is that RI is critical to an institution’s overall financial health. Optimal, correct, and unimpeachable reimbursement is essential for top-quality patient care.”
Setting a Program’s Priorities
Within Weiss’s program, the high-dollar services are the top priorities, along with those of high risk and high frequency. “We focus on the outpatient service lines, as Medicare has many billing and compliance rules related to outpatient claims. Outpatient cardiac procedures, chemotherapy, and drug infusion areas are the high-dollar areas that we audit and review internally before the claims are released. Pharmacy has become a high-priority area given recent changes in Medicare rules for reporting drug waste.
“In terms of risk, we work with our compliance officer to become aware of issues on the OIG [Office of Inspector General] workplan and keep abreast of regulatory requirements issued by CMS and our local Medicare Administrative Contractor,” she says. “In the ED, a high-frequency area, a single flaw in a system could be detrimental if it were to occur repeatedly. This is an area that we monitor on an ongoing basis as well. The overall approach we take is based on these guiding principles but may not be foolproof. We are aware that there are always opportunities we can learn from to improve performance.”
“And it needs to always start with the patient,” Poleon adds. “If we’re providing quality patient care across the board, revenue will definitely follow.”