Decision support tools can help revenue integrity staff focus audits

While revenue integrity auditors require access to the claims system to conduct their reviews, they first need reports to help them identify variances worthy of investigation. Many organizations use a denial management application that provides frequency reports based on payer and type of denial.

But revenue integrity staff monitoring activities go beyond denials to also look at edit frequencies, unusual charge description master item usage, spiked charges (such as frequency changes in the emergency department levels or clinic evaluation and management level), bad mail, remittance adjustments that vary from managed care contracts, write-off categories, charging patterns, service area-specific trends, and so forth.

Since revenue integrity auditors needs access to reliable data, it is imperative that the department has one or more individuals who have been thoroughly trained in the claims system’s report writing tool. This may require the organization to pay for specialized training at the claim system headquarters or participate in an online training session. Investing in an interactive data analytics application or dashboard that will allow data to be viewed in real time is very beneficial to identifying trends earlier than retrospective approaches.

Decision support reporting systems come in varying types. Consider decision support system options that are set up in a way that allows you to work with a few modules to see if it is user friendly and meets your needs. Add additional modules as needed over time rather than incurring a significant one-time capital expense for a package of modules that you may not end up needing.

For more information see The Revenue Integrity Manager’s Guidebook.