Revenue Integrity: Beware the High-Risk, Pre-Bill Approach

Johnny PezzutoDecember 18, 2019


Try to imagine what it would be like if all claims were clean, compliant and processed without human or technological intervention. Hold that thought a little longer and you’ll see health systems getting accurate reimbursement for the care they provide, and physicians focusing solely on patients. This utopia seems a long way off, but revenue integrity solutions are moving us in that direction.


One model a lot of health systems ask about is technology enabling pre-bill capabilities. Pre-bill reviews claims before they are submitted to find missing or inaccurate coding, charges and documentation errors. As accounts are flagged, a certified coder audits the medical record for each account to confirm the opportunity. Pre-bill capabilities sound good, so why are so few health systems taking advantage of them?  


First off, pre-bill solutions are not usually tailored to facility-specific contract reimbursement terms and caveats. For instance, many contracts have timely filing parameters that allow you to recoup revenue on accounts over a year old. A pre-bill only approach negates these retroactive opportunities, which could cause you to leave millions of dollars on the table. A second challenge is that pre-bill doesn’t allow health systems to prioritize potential opportunities based on net revenue impact. All missing charges are treated the same, causing coders to chase discrepancies with no return and overlook high-dollar opportunities.


The pre-bill approach poses another risk to health system finances. Accounts flagged in pre-bill reviews are put on hold from three to 14 days while reviews to take place. The sheer volume can overwhelm coders, especially if revenue integrity vendors are overly conservative and flood health systems with false positives. Since it’s often impossible for coders to review all accounts during the bill hold timeframe, many claims are passed along without proper investigation of missing or inaccurate information. Pre-bill reviews extend the bill hold time even further, increasing accounts receivable (AR); discharged, not final billed (DNFBs) and avoidable revenue leakage.


Accounts held for further review can also impact charge lag. A small percentage of health systems capture charges within 24 hours, but most take days and even weeks. Implementing the pre-bill method only increases lag times.

Every situation is different, but before you put all your eggs in the pre-bill basket, carefully consider the pros and cons. You may find a comprehensive approach combining pre-bill and post-bill methods is the best way to recover the most revenue possible.





Download our latest white paper for a brief overview of the missteps organizations commonly make when attempting to address revenue leakage, that if left unchecked can derail a revenue integrity program.


Author Bio: Johnny Pezzuto is a Senior Director of Revenue Integrity Solutions at R1.