What Is Revenue Integrity in Healthcare?

Every industry is brimming with buzzwords and trends leaving many of us wondering what the latest one has to do with our lives. Relevance is important. Have you recently come across the term ‘revenue integrity’ and wondered what it really means? You’re not alone.

Revenue integrity (RI) is a subjective term and its interpretation can change based on personal opinions. However, in healthcare it refers only to one thing: to generate revenue through every single patient encounter simultaneously maintaining compliance and avoiding any revenue leakage. Essentially, it is a holistic encapsulation of the term revenue optimization and includes legal as well as contractual compliance.

Having said that, you may ask, what is revenue integrity in healthcare? This blog features a complete overview of everything you need to know.

RI in Healthcare – Explained

Revenue integrity plays an important role in RCM operations. People, processes and platforms are important for its maintenance. You can avoid revenue leakage by identifying and resolving revenue integrity issues before every clinical encounter.

According to the National Association of Healthcare Revenue Integrity (NAHRI), revenue integrity’s goal “is to prevent recurrence of issues that can cause revenue leakage and/or compliance risks through effective, efficient, replicable processes and internal controls across the continuum of patient care, supported by the appropriate documentation and the application of sound financial practices that can withstand audits at any point in time.”

Revenue integrity is a bridge that helps connect all revenue cycle operations with clinical coding. The results include efficient workflows and increased revenue. You can optimize your revenue integrity by implementing the right processes, appointing the right people and utilizing the right platforms.

As the focus on revenue integrity and its management is increasing, healthcare setups need to identify classic issues that can affect RI.

Maintaining Revenue Integrity – Challenges

Let’s look at some common challenges that healthcare providers face in their efforts to maintain revenue integrity.

Delayed or Missing Charges

Generating bills is a complex process that includes paperwork filing, sorting contracts, calculating treatment costs and much more. Errors in any of these steps can directly result in loss of revenue. Discrepancies in medical coding also contribute significantly to revenue loss.

Compliance and Price Transparency

Healthcare providers must comply with federal regulations, including Health Insurance Portability and Accountability Act (HIPAA), Systems and Organization Control (SOC) I and II. Compliance helps maintain price transparency and revenue integrity.

Payment Discrepancy

In most cases, patients do not pay for services in full. Instead, insurance providers settle the balance amount by directly depositing it into the hospital’s bank account. Subsequently, the payer sends a payment record to the medical billing office of the healthcare service provider. However, the payment record may not always be aligned with the actual deposit. It takes time and money to correct such discrepancies.

Avoiding all these errors can help maintain revenue cycle integrity. Now that you’ve explored the challenges, let’s look at some revenue cycle best practices.

Maintaining Revenue Integrity – Best Practices

Healthcare practitioners focus all operational efforts around revenue integrity. It helps to follow a set of best practices to avoid revenue leakages. Some of these best practices are as follows:

  • Analyze all workflows ranging from appointment scheduling to medical billing for any inefficiency or compliance issues
  • Ensure optimal functioning of key processes like coding, billing and documentation
  • Create transparency at all stages of the revenue cycle
  • Outsource revenue cycle operations to maximize efficiency
  • Review and update RCM technologies for insights that help you make informed decisions

Hopefully, you now have answers to the question, what is revenue integrity?

It may be complex to maintain revenue integrity as each step of the revenue cycle requires specific skillsets. It’s important to make sure all workflows integrate efficiently. It could be expensive to hire resources to lead or manage revenue cycle integrity. In such cases, outsourcing is a workable option.

HelioNext can assess and streamline your RI efforts with its extensive industry experience, technology, expertise and best practices.

Contact us to get started.