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Revenue Integrity - The Wilshire Group

Our Services

Revenue Integrity

What We Do

The Wilshire Group is dedicated to a business and support model that will yield lasting results for your organizational initiatives. We employ cost-effective methodologies, leveraging some of the brightest minds you will encounter to help your programs reach their maximum potential. We know that you set the bar high for your organization and staff but achieving desired outcomes isn’t always straightforward. Our assessments, collaborative approach, and prowess for fine-tuned project management and delivery can get you there. We pride ourselves on partnering with organizations large and small to set and accomplish goals, reach new heights, and push the boundaries of what is possible in healthcare.

Services and Approach

  • Our team is comprised of industry-leading operational and information technology experts who are pioneers in the revenue integrity space, developing and deploying strategies long before revenue integrity became a popular buzz word.
  • Our team prides itself on a collaborative approach. We have a knowledge base that spans the revenue cycle. The Wilshire Group leverages resources across access, clinical documentation and charging, coding, and billing teams, each of which can have a significant impact on back-end flows.

To truly maximize your revenue integrity implementation, standardization, and optimization projects, it’s pertinent to factor in these transition points. Our team of Revenue Integrity experts at The Wilshire Group understands how to seamlessly integrate these areas to ensure your organization reaches its maximum potential.

Certain revenue integrity initiatives require targeted analysis – we have the ability to take focused approaches to address specific areas of concern. Other services include Net Revenue Investigation and Optimization, CDM design and maintenance services, and strategic pricing initiatives, which can be found more detail below.

Our Support Specialties

Brief Description of these specialties

Net Revenue Investigation

It is important for every organization to reduce or eliminate missed revenue opportunities. Unfortunately, identifying and fixing these leakages can be tough. Missed revenue opportunities can come in a variety of forms and complexities such as missing charges, inefficient provider scheduling, incomplete documentation or charge triggering, or inappropriate contract build. If undetected or unresolved, these issues can result in a massive sum of preventable losses.

These losses hinder hospitals struggling to meet net revenue collection goals. Even if you are a high performing health system, you may still be missing out on more. Don’t let good be the barrier to great. Let The Wilshire Group help.

Our experience spans a variety of health systems from large multi-hospital academics to local children’s hospitals and everything in between. We have seen first-hand the impacts of not collecting all potential revenue, and we want to help you optimize your integrated revenue integrity team to its’ fullest potential. The Wilshire Group team knows where to look for revenue opportunities which can quickly make a positive contribution to your bottom line. Most importantly, our focus is not just on finding these problem areas but developing a strategy to maintain best practice going forward.

Net Revenue Optimization

Increasing net revenue is not solely focused on finding and eliminating revenue leakages. It also includes increasing and accelerating payments, minimizing resource costs, and eliminating excessive and unnecessary workflows through automation.

If you are having troubles receiving timely payments, it’s crucial to understand the why. More than likely, it’s something you can control or fix. High denial rates, increasing delinquent payments, and large volumes of variance records can often point to other issues upstream in the revenue cycle.

Like payments, inefficient workflows build up as you progress further down the lifecycle of a charge. A few extra clicks early in the lifecycle of the patient could cause even more issues downstream, resulting in 10-20 extra clicks for the biller. While not always the case, it is important to be cognizant when looking at workflows of your staff to know whether there is a simpler way of achieving similar or better results. Our team at the Wilshire Group is experienced in analyzing user workflows and identifying opportunities to decrease clicks and streamline upstream workflows which might be causing issues further down in the revenue cycle. These work efforts free up staff hours to focus on higher value tasks.

In addition to minimizing resource costs through simplified user workflows, we can help your organization identify opportunities for automation. If you feel like there are workflows that are taking too many clicks or there are workflows you want automated, we can complete an in-depth analysis and provide you the options available along with an action plan for implementing these options.

EMR Revenue Cycle Implementation

Deploying a new EMR is one of the most complex undertakings a health system can experience. Successfully implementing an EMR so that your organization barely skips a beat is even more difficult. At Wilshire, we have a wealth of EMR implementation experience with an average of years spanning our team of certified Epic consultants. We understand the consequences of not implementing your EMR solution correctly the first time, and we will be there every step of the way to guide you through this process. With clinically focused revenue cycle consultants and back-end revenue cycle consultants together, we will assist your organization in ensuring your integrated revenue integrity team shines throughout the implementation.

Our services include:

  • CDM Scoping, Design, and Implementation
  • Strategic Pricing Analysis
  • Charging Interfaces
  • Laboratory
  • Perioperative Systems and Supplies
  • Inpatient
  • Outpatient Ambulatory
  • Radiology and Cath Lab
  • Emergency Room
  • Coder Workflows
  • Technical and Professional Billing
  • Claims
CDM/Charge Master Services

The charge master is the backbone of your organization’s revenue integrity team so it’s important to treat it that way. Outdated, incomplete, or erroneous charge masters can cause many headaches, and we are here to ensure you do not continue to encounter charge master issues plaguing your organization. Regardless of your organization’s current EMR system, The Wilshire Group can assist. We have experience with a multitude of EMR’s and understand the importance of a well-defined and structured CDM that promotes compliance across your organization.

Our team is experienced in all aspects of the charge master including:

  • Assessing, distinguishing, and documenting issues with the CDM and the charge capture processes
  • Reviewing CPT/HCPCS coding, with code combination, modifier, revenue code, and line item description changes
  • Reviewing charge master designs ensuring your charge master reflects the most up to date charge compliance and regulations, including CDM processes and procedures, how codes are selected and charged
  • Planning and providing recommendation for strategic pricing initiatives, balancing revenue capture optimization and competitively priced service offerings
  • Unifying unique CDMs in preparation for multiple hospitals and/or departments mergers and acquisitions
  • Consolidating your current CDM in preparation of an Epic implementation
  • Implementing clinical/charge master communication processes to increase transparency and reduce potential errors
  • Educating for long-term maintenance to include recommendations for change, strategies for implementation of corrections and changes, and guidelines for ongoing management of the charge master.
Supply and Pharmacy CDM Design

In addition to standard CDM design services, we offer specialized services to assist your organization in transforming your legacy supply and drug records into Epic’s standard SUP and ERX formats. Converting to the dynamic design of Epic’s OpTime and Willow charging modules requires careful consideration and group collaboration to ensure this charging functionality is implemented correctly.

We will guide you through the entire process starting with an analysis of your current state charging in each of these areas. Next, we will design future state determining the ERX and SUP records to create in Epic, build mark-up tables with strategic pricing, and identify processes for linking these records to CDM EAP charge codes. After we assist you with build, we concentrate on the testing methods designed to validate build accuracy.

Throughout the course of our SUP and ERX design, we will leave you with a long-term strategy for strategically pricing and any changes, additions, and subtractions to SUP and ERX records.

Strategic Pricing Initiatives

In today’s environment, competition for hospital services are heating up and there is an increased importance on the transparency of pricing for the patient and the organization. Balancing the need to optimize revenue capture and offering competitively priced services to patients is an area we can assist. Too often, organizations are lacking a structure for pricing services correctly and consistently.

We understand the value of a standard pricing structure that allows your revenue integrity team to follow a consistent approach to updating service rates. Additionally, we understand the importance and impact these pricing changes can have on your patient population and contractual obligations with payors. Our approach doesn’t just stop at your organizations pricing mechanisms but expands out into the proactive communication of these pricing strategies that can be seen in your patient estimates, payor claims, and patient statements.

Our process is designed to assist hospitals and medical centers with defining an appropriate price structure that changes net revenue for a given level of gross revenue, while considering the market for services. The resulting price structure is based on an analysis of each charge-item’s relative contribution based upon payor mix by service area. The payor mix measures what portion of each additional dollar in gross revenue becomes net revenue when rates are changed. Additionally, we obtain the most current market pricing information available for consideration when setting prices.

Three of our main strategic pricing initiatives are:

  • Corporate CDM/Charge Master Standardization
  • Pharmacy Formulary and Mark-Up Standardization
  • Supply Pricing Standardization
Revenue Integrity Process Standardization

It’s natural for organizations to operate in silos whether it’s a large health system or a small community hospital. This holds especially true as many organizations are merging, acquiring, or strategically partnering with other organizations to reduce costs by achieving maximum economies of scale on people and tangible resources.

With an emphasis on moving quickly to take a new department, hospital or EMR live, the importance of long-term standardization is often pushed to the way-side. Meanwhile, increasing regulations, audits, and penalties require hospitals to focus heavily on risk mitigation. Standardizing processes across providers, departments, and organizations is the first step in mitigating a major risk that can occur from these naturally defined silos.

The Wilshire Group has a proven track record of success working with our clients to decrease risk, increase standardization, and improve operational efficiency. It doesn’t matter the size or the issue. We have worked with small community hospitals looking to implement standard communication processes for new charge codes. We have also worked with large multi-hospital health systems that are acquiring hospitals and forming strategy relationships with others.

Clinical Charge Capture Analysis and Optimization Solutions

Each clinical area in a hospital presents a unique set of difficulties whether that’s contrast charging in Radiology or successfully running a FQHC clinic in your outpatient ambulatory settings. With each set of difficulties comes a unique set of risks for issues and revenue loss.

The issue can be as simple as not knowing if your preference lists are set up for efficient use from a clinician. It could be that you’re not using charging on documentation to its fullest extent or maybe not using it at all. It could also just be that you’ve decided coders should be reviewing or triggering all charges, and you’ve taken the responsibility entirely out of clinician’s hands.

Regardless of the specialty you are looking to enhance, The Wilshire Group can help. We emphasize an integrated approach that will ensure all parties involved will walk away better geared for success in your specialty’s charge capture approach.

Perioperative Charge Capture & Cost-Analysis Solutions

The perioperative room is more often than not the bread winner of an organization, the area bringing in the most revenue. It’s also one of the easiest areas to have issues when it comes to charge capture. Despite sophisticated automation with the consistently improving EMR platforms, there are too many components involved to rely solely on automation for charge capture. It’s not just your clinical team involved, it’s your supply chain, IT team, and revenue cycle. Coordinating these groups into a well-oiled machine that functions as one is complex.

When looking to optimize and enhance your perioperative areas, it’s important to understand each of the parts responsible and bring in a team that can look at each area under a close lens. Chances are, there are opportunities in each phase of the perioperative charge capture process that can be improved at your health system. Our hands-on guidance and experience can help you do this by focusing on these key areas:

  • Supply master clean-up and HCPCS coding review
  • Case cost solution design and implementation
  • Physician preference card improvement
  • Supply pricing strategies
  • One-time supply process
  • Case tracking improvement
Pharmacy Formulary & Drug Coding Solutions

Pharmacy billing is an intricate process that requires many moving pieces to function together for billing to occur successfully. In addition to a clear set of policies, it is important to have an update to date medication load with the corresponding CDM matrix, and the correct mark-up tables developed. With so many pieces impacting the cost of a singular medication, it is vital to have policies and procedures for making changes to the pharmacy formulary, updating pricing methods, and ensuring the appropriate interfaces are reconfigured to account for these changes.

On top of this, the stakes are the highest in the pharmacy, where an incorrect mark up table or a missing charge code can cause a significant impact to revenue. Developing polices, conducting audits, and adhering to yearly changes and regulations can be a large undertaking. Fortunately, we can help you with each of the major pain points in your pharmacy:

  • HCPCS coding & billing multiplier review
  • Defensible pricing, cost and markup analysis
  • Self-administered drug policy and identification
  • Non-formulary medication analysis
  • National drug code (NDC) clean-up
  • Interface review of pharmacy medication stations
  • Inventory audits

To learn more about these packages and what we can help you achieve, contact