Q&A: Revenue integrity review strategies

Q. What strategies can facilities employ for effective revenue integrity reviews?

A. Because errors can originate from any of the three major claim data sources (order/charge entry, CDM, and coding), revenue integrity initiatives must include a monitoring or auditing program. According to a perspective brief by Parallon Revenue Cycle Services’ Scott Armstrong and Janet Jones, audit plans are crucial when implementing an audit program. The audit plan can be simple or complex depending on the size and composition of the organization and expectations of leadership (Armstrong & Jones, 2015). Revenue integrity internal auditing programs typically focus on the four activity categories: claims, pricing, CDM, and coding. These internal audit programs aim to identify opportunities for improvement and provide performance feedback to departments.

As we peruse the four major activity groups later in this chapter, we see how many options there may be to identify some of the opportunities to adjust, capture, and recapture entitled reimbursement. To facilitate the auditing effort, organizations may employ an electronic auditing application that maintains the audit schedule and manages audits for different purposes, such as patient (complaint) audits, third-party/insurer audits, compliance department-initiated audits, revenue integrity department reviews, and internal coding audits.

Although the revenue integrity staff may not be the individuals conducting each of these reviews, the results from the reviews will be of interest to revenue integrity staff as well as the organization’s compliance department.

For more information, see The Revenue Integrity Manager's Guidebook.

Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered.