Core functions of revenue integrity
The term and concept of revenue integrity began emerging early in the 21st Century. This emergence was partly in response to concerns that phrases such as maximizing and optimizing revenue might imply gaming or failure to comply with regulations, laws, and business ethics. Using the term “integrity” acknowledges compliance with requirements as well as ethical business practices in obtaining and managing revenue.
The National Association of Healthcare Revenue Integrity (NAHRI) states that the basis of revenue integrity 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 are able to withstand audits at any point in time. This definition was not easy to arrive at, because revenue integrity encompasses so many functions that must be coordinated and integrated in a manner that continuously results in root cause correction and process improvements. The tenets outlined in NAHRI’s definition are at the heart of effective revenue integrity.
Also key to revenue integrity is a sound understanding of the revenue cycle processes, including the following:
- Front-end processes, such as patient access and provider credentialing
- Midcycle processes, such as documentation, charge capture, and coding
- Back-end processes, including claim production and billing, follow-up and collections, payment review and payer contracts, denial management, and financial and key performance indicator reporting
Revenue integrity is woven into each of these processes and surrounds them with additional elements, such as sound compliance and privacy practices, automation and technology, leadership and mentoring of staff, demonstration of ethics at the highest level, diligent monitoring, analytics, and anticipation of changes in the healthcare reimbursement and regulatory landscape.
Editor’s note: This is an excerpt from Core Functions of Revenue Integrity, published by HCPro.