Revenue integrity experts are crucial to identifying and preventing recurrent issues that can cause revenue leakage, degradation, and compliance risk. They are the glue that binds clinical operations with coding and business office functions within any care setting to optimize revenue.
Different team members have various skill sets and expertise, but they all work together to validate quality reporting, provide compliance, and diminish risk while driving efficiencies. This collaborative effort is especially important as clinicians involved in charge capture record information for medical coders. These coders must remain compliant when relating diagnosis and procedure to each claim.
As coding continues to grow in complexity, healthcare organizations depend on revenue integrity professionals to further act as a bridge between clinical, coding, and revenue cycle operations. As these areas merge with greater operational efficiency, they create better compliance in coding and billing practices, resulting in fewer external audits and also fewer payment denials.
Let’s look at the impact this has on a healthcare organization, including in its virtual care delivery.
How can revenue integrity support telehealth?
Revenue integrity prioritizes “an approach to coding encounters in a way that maximizes legitimate reimbursement.” Beyond contractual and ethical compliance are the ever-evolving goals in the healthcare industry:
- managed care/value-base payment plans: measurement of quality outcomes is critical
- traditional fee-for-service plans: code and modifier combinations are critical
We can look at this in the 3 core functions of revenue integrity: front end, middle, and back end. In the front end, revenue integrity plays a crucial role, as it is “important to understand how to apply coverage policies to the providers’ services and the clinicians’ orders.” In the middle, coding, utilization review, and case management are the focus. And in the back end, organizations manage patient financial services and look for “missed opportunities for pre-claim edits or a correction of the root cause to prevent the edit altogether.”
But how specifically does this connect to telehealth?
There’s no doubt that consumers have embraced virtual care options. This revolution has certainly opened the door for more accessible and convenient care delivery as well as more revenue, but challenges certainly still lie ahead. Where there is rapid growth in healthcare, there are surely billing errors and claims denials to follow.
Enter revenue integrity experts.
Audit plans have been announced from the Office of Inspector General; they require providers to pay special attention to how they document and bill telehealth related to COVID-19 discharges. As these plans and regulations continue to evolve along with telehealth, having experts who can institute best practices is “paramount to getting out in front of billing issues and ensuring complete capture of all appropriate revenue opportunities.” Not leaning into the impact these experts can have on organizations can lead to “unavoidable revenue cycle bottlenecks” and can limit organization’s ability to “capitalize on all appropriate reimbursement opportunities.”
To ensure front end, middle, and back end operations are sustainable, organizations must “by design connect clinical operations with coding and business office functions” with sound revenue integrity practices. That must include the growth of telehealth and the evolution of reimbursement regulations , as organizations “simply cannot afford the luxury of leaving money on the table.” The demand for this type of care delivery has skyrocketed more quickly than reimbursement protocols have evolved. To not leave any money on the table means providers must document everything during telehealth visits, including what requires follow-up.
Consulting with a revenue integrity partner
As healthcare providers struggle with claims denials, it becomes increasingly evident that specialized expertise is needed to support revenue integrity functions. Experts can establish the workflows that create this knowledge base by building bridges and ensure operations aren’t siloed. More specifically, they can also:
- reduce the amount of aging accounts receivables and unbilled days
- manage unbilled dollars by prioritizing on high dollar claim follow-up
- expedite cash flow through better management of claim edits and denials
- eliminate problematic trends with proactive monitoring of billing edits, claims rejections, and denials
- ensure accurate charge capture and provide a layer of protection against risk of missed revenue
- identify issues that require education with action plans and process modifications
- foster continuous improvement of revenue cycle processes through ongoing education of compliance expectations and coding requirements
Consulting with a partner that can deliver revenue integrity professionals supports your organization’s objectives and removes the hiring burden. This means your organization can devote more time to underpinning physicians’ approach to telehealth and value-based care initiatives. This will ultimately help you see an increase in a net collection and revenue capture while reducing compliance risk.
The bottom line
- Revenue integrity experts are the glue that binds clinical operations with coding and business office functions within any care setting to optimize revenue.
- Revenue integrity experts support the revenue cycle, diminish risk while driving efficiencies and optimizing payments, and support solid telehealth reimbursement.
- Consulting with a partner that can deliver revenue integrity experts means you can devote more time to underpinning physicians’ approach to telehealth and value-based care initiatives.
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If you’re looking for highly customized and scalable expertise within reimbursement, population health, and health information technology, we’re primed to accommodating your organization’s needs.
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