Revenue integrity continues to be a hot topic in healthcare, even as its exact definition is still being hashed out. Broadly, revenue integrity focuses on reducing compliance risk while ensuring optimal reimbursement. The National Association of Healthcare Revenue Integrity (NAHRI) dryly states the goal of RI is “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 its recently published revenue cycle technology trends report, the Healthcare Financial Management Association (HFMA) identified revenue integrity as the top priority for the health system and hospital leaders for the third year in a row, with nearly 30% of respondents prioritizing this area. Organizations are leveraging technology and partnering with outside experts to improve revenue cycle performance, with nearly half (46%) of those surveyed indicating they are collaborating externally, exploring outsourcing, and vendor partnerships as a means to achieving performance improvements. See more statistics on revenue integrity from HFMA in the diagram below:1
The importance of revenue integrity in terms of outreach and outpatient laboratory services becomes evident when one considers the significant monetary penalties the OIG continues to levy against clinical providers for laboratory regulatory and rule violations — even when unknowingly committed. A quick search of the OIG web site provides an idea of the extent of the scrutiny under which laboratories operate.
Complying with an organization’s revenue integrity program requires optimizing reimbursements that have been applied against the thousands of constantly-change rules and edits that exist for laboratory billing. And as complicated as government payors make the process, it is even more cumbersome maintaining revenue cycle compliance against the millions of rules imposed by private payors.
Hospital leaders tasked with creating, implementing, and maintaining a comprehensive revenue integrity program could find themselves overwhelmed by the high volume/low reimbursement laboratory environment. When identifying violations, the OIG often levies fines based on the number of claims in violation, not the dollar value. It calls into question whether health systems and hospitals have the resources, both people and technology, to effectively manage revenue integrity in this complex and frequently changing environment.
With the increased focus on revenue integrity within healthcare systems, it is more important than ever to have systems and technologies in place that were built out of the gate for compliance and financial reconciliation, and are designed to stay that way, even as rules and regulations change.
In the coming months, we’ll delve further into revenue integrity issues and best practices.