Preparing for today's challenges. Presentation includes key components and industry trends, organizational success factors, key performance indicators, and a client case study.

1. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED1 Confidential and Proprietary
JANUARY 31, 2019
GA HFMA
REVENUE INTEGRITY:
PREPARING FOR TODAY’S
CHALLENGES

2. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED2 Confidential and Proprietary
AGENDA
• Key Components and Industry Trends
• Organizational Success Factors
- Developing a Successful Revenue Integrity Program
- Best-Practice Revenue Integrity Structure
- Project Timeline and Milestones
• Key Performance Indicators
• Client Case Study
• Questions

3. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED3 Confidential and Proprietary
KEY
COMPONENTS
AND INDUSTRY
TRENDS

4. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED4 Confidential and Proprietary
REVENUE INTEGRITY – DEFINITION
Revenue integrity is the source of quality assurance within revenue cycle
• Bridges the gap of knowledge between clinical and billing operations
• Shifts traditional focus of retrospective auditing to proactive charge
management
• Increases both gross and net revenue capture, as well as compliance, by
viewing the big picture
Concept of bringing revenue cycle, managed care, finance, and clinical
together to create a global view of gross and net revenue capture

5. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED5 Confidential and Proprietary
REVENUE INTEGRITY – COMPONENTS
Integrated group of stakeholders focused on the organization’s ability to properly price, accurately
capture and reconcile charges, as well as receive timely and accurate payments for services performed
DENIAL PREVENTION
• Ensure all charging-related denials
are appealed and root causes are
identified within the Revenue
Integrity team
• Track and report recovery efforts
and issues with payers,
departments, and contracts
PAYMENT VARIANCE
• Monitor payments and
address variances in
reimbursement
• Review appropriateness of
pricing and fee schedules
COMPLIANCE
• Develop and implement system-
wide compliance education
• Research regulatory compliance
as it relates to charging
CDI
• Responsible for improving the quality
and completeness of clinical
documentation
• Facilitates and obtains appropriate
physician documentation for any
conditions or procedures
CHARGE CAPTURE
• Reviews documentation to
ensure timely, accurate, and
compliant charge capture
• Educates and trains to
improve charging processes
CDM AND PRICING
• Responsible for the updates to
department charge codes
• Oversees the daily
maintenance, regular updates,
price impact analysis

6. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED6 Confidential and Proprietary
HOLISTIC GUIDING PRINCIPLES
• Provide a central point of
communication to system-wide revenue
generating and support departments
• Focus on creating a collaborative
mentality across the system when
interacting with clinical stakeholders,
finance, managed care, and revenue
cycle
• Drive standardization and accountability
throughout the organization
• Ensure compliant, accurate, and timely
charging from the clinical side to ensure
reduction of denials and accurate
reimbursement
• Provide education, training, and
accountability related to charge capture
and revenue reconciliation
Revenue
Integrity
Managed
Care
Revenue
Cycle
Clinical
Finance

7. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED7 Confidential and Proprietary
BEST PRACTICE REVENUE INTEGRITY STRUCTURE
Documentation
and Coding
CDM and
Pricing
Denial
Mgmt
Payment
Variance
Gross Charge
Capture
Accuracy
Training /
Education
Claim Edit Review and
Revenue Reconciliation
CDM / CPT
Review and
Maintenance
Revenue Integrity
Revenue Integrity – HB and PB
• Acts as a liaison to other revenue cycle and clinic department(s) to monitor revenue flow
• Addresses sources of revenue leakage and areas of revenue opportunity
• Owns all gross and net revenue related analytics
• Ownership of charge capture, revenue reconciliation, and training / education at the department level
• Monitors service line pricing variances and develops associated pricing strategies
• Organizes payer trends with denials and payment variances
Charge-Related
Denials and Avoidable
Write-Offs

8. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED8 Confidential and Proprietary
IMPORTANCE OF A COMPREHENSIVE REVENUE INTEGRITY
PROGRAM
Revenue Integrity Program
• Centralizes committees and/or task forces and goal setting
• Increases transparency of goal setting and achievement
• Tasks and primary responsibilities are interrelated
• Liaison for gross and net revenue discussions across the system
• Decreases risk of missed or inaccurate charge capture
• Increases communication across the system highlighting
opportunities for additional net revenue realization
Lack of Revenue Integrity Program
• Siloed efforts between clinical and revenue cycle
• Mixed messages on proper processes and education
• Complex problems are misunderstood or ignored, and often
don’t receive the necessary focus to resolve
• Increasing trend of revenue assurance programs results in
better margins for competitors – not having an revenue
assurance program will ultimately result in mid- to low-tier
revenue cycle performance

9. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED9 Confidential and Proprietary
ORGANIZATIONAL
SUCCESS
FACTORS

10. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED10 Confidential and Proprietary
DEVELOPING A SUCCESSFUL REVENUE INTEGRITY PROGRAM
People
ProcessTechnology

11. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED11 Confidential and Proprietary
DEVELOPING A SUCCESSFUL REVENUE INTEGRITY PROGRAM
People
1) Identify stakeholders impacting gross and net revenue
capture
• Strategic decision makers
• Clinical service providers
• Payer / contract experts
• Billing and financial specialists
2) Define goals and accountability structure
• Individual vs system goals
• Individuals responsible for attaining goals at all levels
3) Create communication paths across these key stakeholders
• Revenue integrity steering committee
• Service line working groups
• Revenue integrity reports and dashboard

12. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED12 Confidential and Proprietary
DEVELOPING A SUCCESSFUL REVENUE INTEGRITY PROGRAM
Process
1) Identify key processes in gross and net revenue capture
• Pricing strategy and fee schedules
• Payer strategy
• CDM and charge capture
• Clinical documentation review and coding
• Billing and follow-up
2) Assess current state
• Determine whether missing, underdeveloped, or underutilized
• Compare against best practice organizations
3) Develop future state plan and implementation schedule
• Prioritize focus around areas with biggest impact
• Set clear and realistic timelines and resource needs
• Assign owners and commit to deadlines
4) Create goals and clear accountability structure
• Assign multiple layers of accountability to ensure goals are met
• Be consistent

13. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED13 Confidential and Proprietary
DEVELOPING A SUCCESSFUL REVENUE INTEGRITY PROGRAM
Technology
1) Identify technology supporting gross and net revenue capture
• EHR(s)
• Third-party vendors and tools
• Reporting and data analytics
2) Assess current technologies and whether they support goals
• Complete cost / benefit analyses to determine if replacing or
augmenting certain vendors or tools is appropriate
• Look for opportunities to automate
3) Create or adjust reporting package and dashboard(s)
• Validate and understand data components
• Ensure consistency across reports
• Help facilitate realization of individual and system goals

14. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED14 Confidential and Proprietary
KEY
PERFORMANCE
INDICATORS

15. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED15 Confidential and Proprietary
REVENUE INTEGRITY CORE METRICS
RI Functional Area Metric
Gross Revenue Capture
Charge Lag Performance
Cost Center Revenue, Volume, and Acuity Trending
Professional Pre-AR
Hospital DNFB Pending Charges
Revenue Reconciliation Performance
Identified Missed Charges
Net Revenue Improvement
Denial Volume
Avoidable Write-offs as % of Gross Revenue
Avoidable Write-offs as % of Net Revenue
Underpayment Recoveries (Internal and External)

16. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED16 Confidential and Proprietary
CLIENT CASE
STUDIES

17. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED17 Confidential and Proprietary
REVENUE INTEGRITY PROGRAM DESIGN AND
IMPLEMENTATION
System Overview
• Statistics:
• 3 hospitals, 8 outpatient facilities
• 1000+ licensed beds
• 1,100 employed physicians
• Revenue Integrity Program Design
• Oversight for hospital and physician RI functions
• Partnered with leaders to promote CI with the revenue cycle
• Implemented policies and procedures for charge capture,
revenue reconciliation, CDM management, denials
prevention, and underpayment recovery
• Established Denials/AWO Prevention Committee, focused on
HB, PB, PAS, and clinical areas and risk mitigation
• Implemented a staffing model including gross and net
revenue functions
• Identified key opportunities through claim edits, charge
reconciliation, and denials management
• CDM and Charge Capture Audit
• Established change control system for CDM mgmt. and audit
• Trained clinicians responsible for charge entry and
reconciliation
• Implementation of Revenue Guardian
Solution Implementation
Key Accomplishments
• Created nine new positions dedicated to RI
• Implemented avoidable write-off strategy to
increase net revenue in first year by >$10M
• Hired system Revenue Integrity Director to
lead new department & functions
• Leveraged vendor partnership to identify
underpayments on $0 accounts($2M benefit)
• Created revenue monitor report at cost
center level
• Improved denial follow up workflow to
capture denial root cause issue & owners
• Improved communication & visibility around
revenue capture at the service line levels:
• Started annual CDM & specialty-based
charge capture audit
• Determined executive Clinical Revenue
Champion to support revenue cycle & clinical
partnership
• Implemented Revenue Guardian checks for
anesthesia services, missing surgical supply
charges, and ED service levels

18. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED18 Confidential and Proprietary
REVENUE INTEGRITY PROGRAM DESIGN AND
IMPLEMENTATION
System Overview
• 8 hospitals, 90 clinics
• 1,500+ licensed beds
• 1,200 employed physicians
• CDM and Charge Capture Audit
- Iterative CDM validation and audit
- Charge capture build audit
- Year over year charge trend analysis
- Improved charging dialogue among service line leaders
- Implementation of Revenue Guardian
• Revenue Management Program Design
- Current state analysis of system processes related to
charge capture
- Organizational structure re-design
- Policies and procedures
- Re-education and training
- Identification of key opportunities through claim edits,
charge reconciliation, and denials management
Solution Implementation
Key Accomplishments
• >4,500 charge codes were identified for
consolidation and standardization
• Automated alt code assignment
• Created six new positions dedicated to
Revenue Integrity
• Accelerated $17.5M (gross) cash over three
months
• Achieved over $13M in net revenue benefit
related to the reduction of avoidable write-
offs
• Improved communication and visibility
around revenue capture at the cost center
and service line levels:
- Started Revenue Management Steering
Committee
- Weekly service line working sessions
• Created revenue monitor report at cost
center level
• Identified >100 charge capture opportunities
• Found >3,000 errors in charge code build

19. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED19 Confidential and Proprietary
QUESTIONS?

20. / ©2019 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED20 Confidential and ProprietaryConfidential and Proprietary
ANDREW HANCOCK
Managing Director
andrew.hancock@navigant.com
Phone: 616.322.6457
AMANDA VALLOZZI
Associate Director
amanda.vallozzi@navigant.com
Phone: 571.213.8463
navigant.com
CONTACTS