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Revenue Integrity department structure


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Revenue integrity is a proactive approach that links together revenue cycle operations, clinical operations and compliance. This presentation reviews how to define a revenue integrity department structure and other best practices.

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Revenue Integrity department structure

  1. 1. Defining a Revenue Integrity department structure
  2. 2. What is revenue integrity Revenue integrity activities benefit the patient, the facility and payers. • Revenue integrity is a proactive approach that links together revenue cycle operations, clinical operations and compliance. • Revenue integrity activities ensure that clean complete claims go out the door, that revenue capture is correct and compliant and that facilities keep the revenue they receive.
  3. 3. Typically, revenue integrity departments are led by an experienced senior revenue integrity leader who reports directly to the VP of Revenue Cycle. Depending on the size of the organization we typically see two other leadership staff reporting to the RI leader: • The CDM subject matter expert and team of charge capture auditors • Trainers to ensure others are educated on best practices What is the basic organizational structure for a revenue integrity department?
  4. 4. We can’t afford to add FTEs is there another approach? If you think of the revenue cycle in terms of an interdisciplinary team, an “assembly line” kind of approach is required to take care of patients and produce a clean claim. This process should not require more full-time employees or increase costs. Instead, the process should involve a redistribution of effort from the back end to the front end.
  5. 5. Which KPIs should RI departments be measuring? Important Message from Medicare (IMM) should be signed 100% of the time for Medicare patients. A joint KPI between pre-services and case management for payer authorization would measure for authorization obtained prior to treatment or admission and measure the time between pre-services’ request for clinical information and the time case management fulfills that request. Number of initial denials and root causes such as duplicate claims, no authorization, and medical necessity.
  6. 6. Is there a certification for Revenue Integrity staff? NAHRI aims to launch the credential in Fall 2018. Information can be found at • There is a new certification coming for Revenue Integrity. • NAHRI is currently developing the Certified in Healthcare Revenue Integrity (CHRI) credential to provide a trusted baseline of competency for revenue integrity professionals in healthcare settings.
  7. 7. Hospitals may think that DRG optimization is a solved problem, but inpatient coding accuracy for ICD-10 is only around 61%. BESLER’s Revenue Integrity Service can often improve accuracy without the need to purchase or learn costly software, potentially increasing inpatient revenue and reducing compliance risks. Watch a short video that explains how BESLER can help improve Revenue Integrity at your hospital