For multiple years in a row, chief executive officers (CEOs) participating in the American College of Healthcare Executives’ annual survey ranked financial challenges as the number one issue facing hospitals. With sound revenue cycle management and, in turn, revenue integrity being essential to survival, the decision to buy, build or replace a revenue integrity solution is one of the most important a hospital can make.
Crucial differences separate revenue integrity solutions from one another. Oftentimes, hospital executives don’t realize the differences until it is too late to turn back, forcing them to make additional investments, spend time and resources filling gaps or risk compliance violations. Of the must-haves they wish they’d known before choosing a revenue integrity solution, these four stand out.
Many revenue integrity solutions vendors have grown through mergers and acquisitions, resulting in a patchwork of disparate systems that don’t talk to each other. Even if individual functions are best-in-class, the lack of integration cancels out their potential value. This problem is exacerbated in health systems whose own mergers and acquisitions have left them with multiple platforms and networks. Unless they choose a one-stop partner rather than niche vendors, the amount of time they spend on vendor management will continue to climb.
One example of the hazards of disparate systems is when a revenue integrity solutions vendor does not offer integrated chargemaster services. An inadequate or noncompliant charge description master (CDM) can lead to overpayments, underpayments, claim edits, denials and unwanted legal exposure. Another example is when a vendor treats strategic pricing as an afterthought. Price stability based on the market and specific contracts is imperative to maximizing revenue and staying competitive. Hospitals who find themselves without a pricing strategy must either partner with another vendor or bring it in-house, both of which can be costly and time-consuming. Furthermore, if billing, coding and denials don’t work harmoniously across multiple facets, revenue leakage will continue.
Most, if not all, revenue integrity solutions vendors make claims to demonstrate the value they can deliver to hospitals. While these claims are often true, they may or may not be meaningful to a hospital’s bottom line.
Missing charges are a prime example. Some vendors who claim to find high volumes of missing charges may include false positives, or errors generated by system rules that do not apply to a particular health system. False positives should not exceed 15 percent, yet some vendors’ rates are as high as 75 percent. In the end, hospital staff wastes significant time chasing missing charges that yield no net revenue lift.
There was once a lot of hype by revenue integrity solutions vendors about pre-bill rules to minimize missing charges up front. The challenge is that this can add to charge capture lag times when bills are put on hold, ultimately spiking accounts receivables. Because this approach is nothing more than a band-aid that must be applied again and again, smart vendors are now shifting to identifying and fixing the root causes of revenue leakage to prevent it from recurring. This is most often accomplished through the right combination of pre- and post-bill models.
When contract management technology is separate from a hospital’s revenue integrity operation, vendors often apply general figures to net revenue opportunities. This means the amount of actual cash they project to generate from missing charging/coding can be very misleading. Some solutions integrate payer contract data at the account level and clearly depict net revenue opportunities. This minimizes time hospitals spend going after missing charges that yield zero net revenue.
Hospitals must do significant due diligence to find the right revenue integrity solutions vendor for their specific needs. One theme is consistent: the ideal way to optimize revenue is with a holistic process and technology-enabled solution from a partner who understands and can address issues throughout the revenue cycle. These four must-haves are the foundation of a solid, long-term revenue integrity solution to ensure hospitals receive accurate reimbursement for the care they provide.
 American College of Healthcare Executives. Survey: Healthcare Finance, Governmental Mandates, Personnel Shortages Cited by CEOs as Top Issues Confronting Hospitals in 2018, January 25, 2019
Johnny Pezzuto is a Senior Director of Revenue Integrity Solutions at R1.