The Future of Revenue Integrity: From Reactive to Predictive – RCM

Patient Engagement
Vasilios Nassiopoulos, Vice President of Platform Strategy and Innovation, Hayes

Healthcare organizations have witnessed an explosion of new opportunities to extract value from the industry’s treasure trove of data in recent years, with success stories related to using advanced technology such as artificial intelligence (AI) and machine learning found in every sector. 

Revenue integrity is no exception. 

Error-prone manual processes that were formerly characterized by painstaking line-by-line analyses of claims are giving way to automation and analytics that can support more efficient and effective auditing practices—essentially moving strategy from reactive to proactive for a healthier bottom line.

The inherent opportunity should not be lost on today’s c-suite, which was already wrestling with tight operational margins before the pandemic pushed many organizations into the red. The reality is that a holistic approach to revenue integrity that considers the past, present, and future of billing practices is fast becoming the best practice that differentiates financially viable healthcare entities. 

Revenue Integrity: How Far We’ve Come

The scope of revenue integrity—a strategy that aims to optimize reimbursements and compliance from the outset of claim submission—originated with processes that were limited to reviewing chargemasters and making sure all codes were up to date. Over time, these processes expanded to include tactics for evaluating possible revenue leakages by ensuring all services and procedures were accurately captured on the front end. 

As these strategies matured to encompass greater collaboration around documentation review between health information management and clinical departments, many organizations identified the need for greater auditing of compliance issues. Consequently, revenue integrity became an integral branch of an organization’s compliance department, and best practices morphed over time to entail greater collaboration between compliance and billing functions. 

Through greater use of automation and analytics, revenue integrity strategies have rapidly evolved over the past five years to support well-honed retrospective auditing practices. Designed to alleviate back-end bottlenecks that occur due to denials management and unnecessary rework, retrospective auditing entails reviewing claims post-submission – preferably following adjudication – as either paid, denied or pending with the goal of identifying problematic trends. Armed with these insights, revenue integrity teams can then educate staff involved in front-end processes to ensure claims are submitted correctly the first time.

These movements have dramatically improved revenue capture. But they shouldn’t stop there.

Next-Generation Revenue Integrity: Predictive and Proactive

Automation and analytics working in tandem with AI, natural language processing, and machine learning techniques, represent the future of revenue integrity. With the right infrastructure in place, healthcare organizations can draw the promise of a holistic revenue integrity strategy that moves beyond retrospective auditing to daily risk monitoring and more prescriptive analytics. 

A holistic strategy brings together the strengths of both retrospective auditing and prospective auditing—processes that address problems prior to claim submission. AI and natural language search can help inform an optimal strategy by detecting anomalies in at-risk claims in near real-time to help healthcare organizations design analytics protocols for prospective audits. For example, algorithms may predict that 40% of COVID-19 related cases will be denied around two main causes: medical necessity and length of stay. Equipped with this foresight, prospective auditing can be designed to spot-check an appropriate sample of those claims before they are submitted.  

Related: Hospital Sustainability Demands that Revenue Integrity Move Front and Center

The University of Utah Health used this strategy to get ahead of the potential fall-out from COVID-19 claim issues as guidance changed frequently. The only academic health system serving the Mountain West, the organization sought to enhance the agility of its 5-person quality and compliance support team and accelerate key aspects of the revenue cycle process by deploying an infrastructure of automation and analytics to support prospective auditing. 

Compliance professionals leverage the platform to audit entities and perform corrective actions to mitigate compliance risks, while revenue cycle professionals leverage the analytics modules to identify revenue risks and take further actions. This allowed the organization to recapture nearly $60 million in at-risk charges and revenues. 

Some more obvious ways that healthcare organizations use prospective auditing to their benefit include:

– New Providers: New clinicians always present risk because they lack historical reference.  The current consolidation and acquisition climate exacerbates the risk, especially when large numbers of new providers are brought in-house at once. Prospective auditing built around new providers safeguards healthcare organizations from the “unknown” and ensures timely capture of revenue.

– At-Risk Providers: Upon identification of an at-risk provider, prospective auditing can get out in front of potential issues while education is underway and new processes are put into place. This minimizes the potential for revenue gaps until the issue is rectified.

– High-dollar procedures: Claims denials across certain procedures—such as transplants, endovascular, and spine—can dramatically impact bottom-line health. Revenue integrity teams will want to design prospective auditing tactics that focus on these procedures to ensure clean claim submission from the outset. 

– High-volume codes: Because a small percentage of procedures often account for the bulk of a provider organization’s revenue, prospective auditing around these codes can pay dividends. 

– New ICD-10 and CPT Codes: New codes that are untested from a compliance standpoint can wreak havoc on denials and optimal revenue integrity practices.  Between COVID-19, telehealth, and the new 2021 E/M coding changes, there are more reasons than ever to be diligent about double-checking charges before they are submitted. 

Optimal approaches to revenue integrity are moving from reactive to proactive as healthcare organizations lay the right foundation for ensuring compliance with the latest regulatory guidance and capturing all appropriate reimbursement opportunities. Achieving a sustainable level of financial health requires a strategy that allows technology-enabled processes to support a holistic approach that brings retrospective auditing practices together with predictive and prospective.


About Vasilios Nassiopoulos 

Vasilios Nassiopoulos is Vice President of Product Strategy and Innovation at Hayes. A senior executive with over 25 years of healthcare experience, he possesses extensive knowledge of EHR systems and PMS software from Epic, Cerner, GE Centricity and Meditech.