Revenue Integrity: It's All About Results

Johnny PezzutoDecember 18, 2019


What matters more: how things work or the outcomes they produce? Take Tiger Woods, for example. If you’re like most of us, you don’t know or care about the technical aspects of his golf game, but you are impressed that he’s won 14 major championships and is one of the world’s highest paid athletes.  


Now let’s apply this line of thinking to revenue integrity. Again, if you’re like most hospital executives, you’re less concerned about what happens in the background and more worried about outcomes. You want to know which solutions produce results, namely, maximum net revenue, compliance and future error prevention.   


Consider manual revenue integrity programs. People can learn and retain only so much information at once. With complex payer language and limited data insights, it’s impossible for anyone to spot every source of revenue leakage. Add in the natural tendency to take shortcuts and make assumptions based on limited data, and your staff could overlook anomalies worth millions of dollars. Bottom line: the effectiveness of a manual revenue integrity solution relies heavily on each person’s skills, limiting results and leading to errors and inconsistencies. 


Another approach to revenue integrity is electronic medical records (EMR)-enabled systems. While better than manual, they’re not error-proof. If hospitals rely solely on these systems, they can be lulled into a false sense of security. Healthcare rules, regulations and individualized payer contracts are increasingly stringent and complex, and even with EMRs’ technological advancements, missing revenue opportunities is common. Health systems must perform audits to validate revenue integrity and continually upgrade their technology to avoid errors. And, disadvantages to pre-bill rules and edits are surfacing, such as longer lag times, higher accounts receivables (AR) and higher discharged, not final billed (DNFBs). When you invest in and rely on the labor-intensive process of building and maintaining rules and still don’t get the results you expect, EMR-enabled revenue integrity is a tough pill to swallow.


Possibly the best approach is to invest in technology-enabled people and processes proven to deliver results. A word of caution: getting caught up in the hype about advanced technologies like predictive analytics and machine learning can mire you in the “how” instead of targeting results, but it’s worth knowing who uses what. Some vendors, for instance, use predictive analytics but can’t incorporate payer contract details or evaluate best practices that allow you to prioritize opportunities to recover the most net revenue. A more comprehensive solution fixes issues for the long-term with few false positives and correct prioritization based on revenue potential. The results are higher team productivity, higher root cause resolution and, most importantly, maximum net collections. As we said, what matters more than how things work are the outcomes they produce.




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.