Revenue Integrity (RI) is often described as a ‘discipline’ that acts as an ‘umbrella’ over the revenue cycle. Others describe RI as an operational department within the revenue cycle. Defining what revenue integrity is, is not really that important. What is important is that the functions of revenue integrity are happening somewhere in your organization. Generally, revenue integrity work resides in the middle of the revenue cycle. If most of your RI team’s time is spent on the back end, clearing edits, working claims, etc., you might want to look at moving more interventions upstream to the middle. This scenario usually indicates there are more opportunities to implement system functionality that supports automation and more exception-based interventions versus constant oversight.
While no two RI departments may be exactly the same, focusing on the work of the RI team can be very beneficial. Wilshire has done a lot of work in the RI space and has developed an eight-pillar program (EPP) which defines a fully implemented and mature RI program. These don’t happen overnight and to my opening point, they don’t all have to look the same. Reporting structures can be different, talent can be different, but there are key functions performed by the pillars. We’ll take a quick moment to look at what Wilshire defines as best practice. These pillars can share talent across teams.
Chargemaster (CDM) Pillar
Manages the organization’s consolidated price list for services and supplies with RVUs. Also defines data strategies for efficient recording and reporting of goods and services provided.
Charge Protocols Pillar
Memorializes, maintains, and socializes, charge protocols for the system. Sets and oversees strategy for custom codes and unlisted codes.
Charge Trigger/Capture/Reconciliation Pillar
Takes responsibility for ensuring the timely and successful recording of revenue. The team is very knowledgeable about how EHRs trigger charges and maintain relationships with their clinical partners to support charge reconciliation.
Charge Audit & Oversight Pillar
Concurrently and/or retrospectively reviews accounts for potential revenue leakage. The team may also perform complicated, centralized, manual charging programs.
Developing and executing internal PI projects using tools like SBARs or others, aimed at finding and stopping revenue leakage. And developing reporting processes to demonstrate the net revenue contribution, or ROI, of the entire RI operation
Compliance & Data Integrity Pillar
Team with deep technical knowledge but on the operations side, charged with translating complex billing rules into streamlined, electronic data transactions. Also has an oversite of Bill Areas in Epic for appropriate revenue routing.
Application Integration (CREW) Pillar
EHR and ancillary module integration from a revenue cycle perspective; identify and correct system issues that are negatively impacting revenue. Leads integration with clinical modules and IT. For professional billing, they focus on cloning in the system and SmartPhrases.
External Government Audits Program (GAP) Pillar
Team to monitor and assess the risks associated with external audits like RACs and the OIG. The team is also involved with billing operations as well as responsible for responding to commercial clinical denials.
Please contact us if you are interested in learning more about Wilshire’s Revenue Integrity 8 pillar program. Check out our Revenue Integrity page to see some of the services we offer in this space. Feel free to reach out to Gretchen Case at firstname.lastname@example.org.