Revenue Integrity is a key component that healthcare providers have included in many performance improvement initiatives. The impetus of the heightened request for Revenue Integrity assistance is due, in part, to the migration of the healthcare payment structure from the customary percentage of charges to a Prospective Payment structure. CMS implemented the Inpatient DRG Prospective Payment System and the Hospital Outpatient Prospective Payment System (HOPPS) in 1983 and 2000, respectively. The majority of third party payers currently follow these coding-driven payment structures. As a result, payment outcomes are a direct result of proper charge capture and reporting of CPT/HCPCS codes for hospital outpatient and physician services. FTI’s Revenue Integrity program is focused on implementing a process whereby there is a clear connection between clinical services and billable events, while utilizing the client’s IT capabilities to generate automated coding and billing information. The accuracy and efficiency of the process design is critically important to drive claims production and the corresponding payment outcome.
Healthcare providers recognize that a fully staffed and functional Revenue Integrity department will result in proper charge capture, coding and final claims reporting outcomes in a timely fashion. The clinical stakeholders would be well informed of the importance of their clinical documentation requirements and their roles in supporting the Revenue Integrity process. The responsibility of accurate and timely reporting of services should be initiated with clinical staff’s proper documentation. The leading practice is then followed by an efficient and effective system design to facilitate proper data flow and claims reporting outcomes.
The required division of hospital UB-04 and physician 1500 claims reporting in the healthcare industry results in dual workforce from coding to account follow-up. In the future “lean” environment, many of the activities can be consolidated. One of the hallmarks of our Revenue Integrity approach is assisting clients to implement the consolidation of workflow and resources, which not only impacts proper revenue outcomes, but also potential reduction of force.