This document discusses strategies for improving healthcare revenue integrity through effective revenue cycle management. It identifies several key areas of risk, including patient access and utilization review, charge capture, and billing and payment accuracy. Deficiencies in these areas can undermine the revenue cycle and result in lost revenue of 3-5% due to a lack of internal controls. The document recommends evaluating processes in high-risk areas like patient access, utilization review, charge capture, and payment accuracy against best practices to identify opportunities for improvement. This includes ensuring accurate information capture, coding, billing, payment reconciliation and reporting to optimize reimbursement.

1. Healthcare Revenue Integrity Strategies
 Using High Value Revenue Cycle Assessments to Protect and
Improve the Bottom Line..
 Healthcare hospitals know that every step counts and there is no room for
error when securing revenues and reimbursements for their services.
However, ensuring revenue integrity can be challenging for these
organizations due to numerous industry complexities. Patient clinical and
billing information, for example, traditionally are managed in isolation by
different departments with very little integration. Thus, it is common for
one department’s deficiencies to impact other departments adversely, as
well as the overall integrity of a hospital’s revenue cycle.
Eg:Front desk, Pre-Auth department, coding & insurance billing
dpeatment each and every dep has their own inportants in revenue
making.
 Deficiencies and avoidable mistakes in key revenue cycle components
undermine the effectiveness of a hospital revenue cycle. Organizations can
fail to realize as much as 3 to 5 percent in net revenue due to a lack of
effective internal controls for mitigating financial, regulatory and
operational risks.
 Hospitals are commonly at risk for losing revenue. They include patient
access,utilization review,charge capture and billing and payment
accuracy.Hospitals should consider evaluating their processes in these
areas against leading practices and, if warranted, also focus on making
improvements.
 Patient Access and Utilization Review
Patient satisfaction and optimal reimbursement hinge on the efficiency and
effectiveness of the first patient touch points. A significant percentage of the
insurance claim form is generated through information gathered during this

2. stage of the revenue cycle process. It is also where errors occur that often
result in avoidable denials. In fact, avoidable denial-related errors made
during patient access activities account for up to 3% percent of total denied
claims in hospitals. Breakdowns in Scheduling insurance verification pre-
authorization Admissions and utilization review processes can lead to
patient dissatisfaction, billing problems, excessive insurance denials and
extensive rework.
 Revenue cycle improvement initiatives should focus on these key
processes, as effectively designed controls for ensuring accuracy of
information prior to or during patient care will enhance patient self-pay
collectability and will significantly reduce resources required for billing
and collection, including claims rework, denials management and bad debt
management during downstream processes.
 Charge Capture
Healthcare provider’s financial success is directly dependent upon accurately
charging for services rendered, especially when there is a strong concentration
of managed care or commercial payers. Based upon the review and study of
data from more than 2 % organizations lose because of errors in the price list
and charge capture processes.
 Billing and Payment Accuracy
The processes of Billing collections denials management and underpayments
management may be routine activities for healthcare providers, but they also
represent key areas of opportunity for ensuring revenue optimization.
Specifically, processes for ensuring payment accuracy, correctly identifying
and resolving denials, and effectively managing underpayments are critical to
maintaining a healthy bottom line. This includes not only the effective
identification of payment inaccuracies, but also the appealing, trending and
upstream reporting to effect improvements in people, processes and
technology.

3. Reconcilation proposal
1) Claim filing & follow up
We should write letter to all the major insurance to going forward we are going to file
everything electronically and keep records. Conduct as much of the correspondence between
yourself, Rejections.
 Identify why your claim was denied. There are many reasons insurance
companies can deny a claim. The first step is to find out why your claim was
denied. Call our doctor, insurance company or hospital as soon as you receive
your Statement of Benefits to find out why your claim was denied. Here are
some of the common reasons for denial:
 Incomplete or inaccurate insurance information
 Lack of pre-certification or prior authorization
 Non covered of tests or procedures
 Diagnosis and procedure coding errors and omissions
 Past timely filing limits
 Insufficient medical necessity
 Co-Pay, Deductible, Patient Portion amounts

 Reason for the rejection
•Inaccurate or lack of coding
• Incomplete claims
• Lack of supporting documentation (Medical records )
• Poor communication with the payer
• Not billing for services rendered
* Not being follow up AR balance claims

4. Coding
Clinic should maintain a coding software which Dr can directly enter the description of
disease & automatically the Dx code will popup on the Emr System , so that coder only need
to justify or audit then they can move to Claim filing department, this will reduce the delay
of claiming, as well as the payment .
Payment posting
Payment posting is simply posting payments from the insurance company into the system. The
insurance company sends a check along with an EOB or aknowldgement . On the EOB the
insurance company will tell you the allowed amount and the amount they paid. You would
then bill the patient any copays, coinsurance or deductibles…….We will get a clear projection of
payment and backlogs.
PMS system & Reports
If the hospital maintain the Practice management system it really helps to identify the issues
of claim, rejection and the revenue, backlog ofclaim & also all finacncial reports . Below are
the report the practice should run……..
 Weekly & Month report :Atlast we should maintain these many report for improve
the reconciliation……. To identify the issues , Improved cash-flow
o Monthly Charges & Collection report
o Payment Comparisam report
o Rejection report
o Corrected / Appeal Claim Report
Health Insurance Refund/excess payment Report