Health care revenue integrity: Panel shares insights and considerations

ARTICLE | November 08, 2022

Authored by RSM US LLP

More than 600 leaders tuned in live for a dynamic panel examining trends and providing counsel on revenue integrity during RSM’s second annual Virtual Health Care Day.

Tina Hodges, RSM principal and national revenue integrity practice leader, and Michael Haas, RSM manager of technology consulting and health care senior analyst, led the panel in discussions about the common roles and responsibilities that drive value of a formalized revenue integrity department, the largest benefits and challenges for defined revenue integrity departments in 2022, and the skills needed for team members to succeed. Panelists included Kenya Bennett, revenue manager for Duke University Health System; John Mendez, an experienced revenue cycle leader; and Robin Zweifel, coding and billing compliance director for BioReference Health.

For middle market health care companies, a few key takeaways and observations from the event included:

• Although providers and industry organizations define revenue integrity differently, there is agreement of the value in key roles and responsibilities that compliantly decrease revenue leakage
• There is broad agreement on the key components of revenue integrity
• Challenges persist with staffing, structures and leadership support for revenue integrity functions
• Leveraging technology effectively is a key component of a successful revenue integrity program

Defining revenue integrity

Revenue integrity has been a buzzword for some time, yet companies define and execute it in a wide variety of ways. RSM broadly defines revenue integrity as an enterprise function overseeing charge capture and quality reporting, with a focus on compliantly generating the highest yield.

The National Association of Healthcare Revenue Integrity defines revenue integrity as:

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 care, supported by the appropriate documentation and the application of sound financial practices that are able to withstand audits at any point in time.

Panelist John Mendez reinforced that the focus should be on documenting all work to ensure work can be billed in a compliant manner. He added that the compliance and revenue cycles need to work together to succeed.

Varying revenue integrity structures, but agreement on key components

In a poll of panel attendees, it became clear that programs vary significantly. More than 45% of attendees said they have a formalized program with dedicated staff and leadership, more than 25% said they have some of the components but not a formalized program, and more than 25% either don’t have a program or may or may not be working to build one.

Panelist Kenya Bennett defined the key components of revenue integrity as:

• People – Finding and retaining talent with analytical and critical thinking skills
• Workflows – Ensuring processes are defined and followed
• Technology – Working with data analytics to identify gaps, and evaluate KPIs and revenue leakage

Aligning the most critical team attributes to succeed in revenue integrity

Meeting attendees agreed that the most important team qualities to succeed are:

• Ability to modify communications to address different audiences, including but not limited to clinical, finance, IT and revenue cycle
• Attention to detail
• Passion to investigate until answers are revealed

Panelist Robin Zweifel added that it is critical that staff members understand the full revenue cycle. She counseled that finding, investing in and training the right people is important and suggested that thinking creatively about how to move people into new and different roles may both challenge them and keep them committed to the organization in the long term.

Differing functional support despite commitment to revenue integrity overall

More than 45% of panel attendees have a formalized program, yet when polled about the five functions critical to revenue integrity success (clinical liaisons, work queues or work lists edits/monitoring, strategic audits, clinical data management analysts, denial prevention) only 19.6% had all five, and over 40% had none.

All panelists agreed that the role of the clinical liaison is a critical role for a comprehensive and effective revenue integrity team. Liaisons provide important perspective on how to make sure data and compliance analyses are relevant to the overall health care provider space. If health care providers don’t agree with the coding, or find coding and systems to be arduous, the overall revenue integrity program is much less likely to succeed. The ability for clinical liaisons to communicate with key stakeholders including clinicians, finance and IT, and adapt their language to problem solve and execute change is imperative for a successful program.

Continued challenges to keep in mind

Many challenges continue to face the teams and leaders working to establish revenue integrity within their organizations. Robin Zweifel summarized that a full team with the right expertise and an appropriate 50/50 split between finance and compliance is paramount.

Kenya Bennett added that support from leadership sets up the function for success. And John Mendez closed with the importance of data and demonstrating tangible value.

For more information on this session and others held during our second annual Virtual Health Care Day, click here. Note: Continuing professional education credits will be issued to eligible participants for the on-demand sessions only.