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December 7, 2020 Readers Write No Comments

Technology: An Essential Element of Holistic Revenue Integrity Strategies for Future Sustainability
By Vasilios Nassiopoulos

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Vasilios Nassiopoulos is vice-president of platform strategy and innovation with Hayes of Wellesley, MA.

Healthcare organizations are facing a perfect storm of financial challenges. US hospitals and health systems entered 2020 with razor-thin operational margins that were exacerbated by substantial and ongoing losses related to COVID-19.

Amid a dramatic drop in healthcare spending during the first quarter of 2020, financial executives found themselves with limited means for countering ongoing pandemic-related impacts, touching everything from supply chain costs to lost billing opportunities and compliance issues. Notably, the industry acknowledges that federal incentives related to the COVID-19 pandemic will not provide enough relief to surmount the far-reaching financial impact.

The heightened role of technology, especially as it relates to use of analytics to inform operational decision-making, proved a key differentiator for keeping many balance sheets in the black and stabilizing the bottom line. In contrast, manual efforts to audit claims and understand potential revenue cycle liabilities and bottlenecks left many organizations reacting to issues late, opening the door for cash flow problems that quickly spiraled out of control.

The advantages of using advanced technological frameworks to inform sound revenue integrity strategies should not be lost on today’s C-suite in their quest to a sustainable, profitable outlook. If healthcare organizations do not act now to proactively capitalize on all appropriate reimbursement opportunities as well as avoid future penalties from audits, the future stability of hospitals in communities across the nations is uncertain.

Progressive revenue integrity strategies bring together all billing and compliance functions in a collaborative way to address billing issues before claims leave an organization as well as via ongoing process improvement. Optimal programs consider:

  • People, through cross-functional steering committees.
  • Processes, by combining the strengths of both retrospective and prospective auditing.
  • Metrics, through established performance-based goals.

Sound revenue integrity processes rely on technology-enabled workflows to speed identification of risks, perform targeted audits, identify and address root causes, and monitor the impact of process improvement tactics. When the right combination of automation, analytics, and artificial intelligence (AI) exist, billing and compliance teams can overcome the barriers of manual auditing processes to gain visibility into patterns and issues, which in turn inform process improvement and corrective action tactics.

Technology can be a game-changer when it comes to minimizing financial risk, improving revenue retention, and often identifying dollars that might otherwise be left on the table. Foundationally, data-driven infrastructures should be designed to promote shared monitoring and auditing processes between members of a revenue integrity team.

A framework of automation should support both continuous and proactive auditing (prospective) of claims before they are submitted and immediate and ongoing monitoring of delayed or denied claims (retrospective). Analytics tools can extract key charge and payment data to provide instant visibility into all prospective and retrospective data sources, eliminating the manual preparation time that often bogs down revenue integrity strategies.

Prospective auditing of claims for proper coding and clinical documentation minimizes denials by ensuring accurate, compliant submissions. Automation that supports ongoing monitoring and analytics can be a critical enabler of these processes in terms of staying abreast of updates and changes across payer reimbursement policies. They can also better enable risk-based auditing practices that prioritize an organization’s greatest risk areas.

For example, telehealth reimbursement has become an important driver of revenue over the past year, as healthcare organizations find ways to safely support care continuity. Advanced solutions that automatically release new ICD-10 codes and telehealth guidance streamline the ability of billing teams to operationalize changes and support ongoing monitoring.

When supported by automation and analytics, retrospective auditing speeds root cause analysis, ensuring rapid implementation of an optimal corrective action strategy to promote submission of clean claims. Analytics can be used to automatically generate key metrics around identified risk areas, allowing revenue integrity teams to benchmark against peers.

Use of advanced AI tools such as natural language processing can further elevate the strategies to improve management of a healthcare organization’s overall financial performance. These solutions can be used to track case mix index, elective surgery trends, and average lag days from denial resubmission to adjudication. Revenue integrity teams can analyze year-over-year and year-to-date trends for Medicare and commercial payers, detecting data anomalies and outliers that barriers to revenue integrity.

Use of AI can deliver a depth of understanding of denial attributes over large volumes of historical data that is typically a non-starter with manual processes. These systems learn from trends over time and can then, in turn, automatically apply identifiers or changes to future claims submitted to various payers. For example, denials related to medical necessity account to almost 10% of total denials. Identifying the root case and applying the necessary edits or process changes will prevent similar denials.

The value proposition of advanced tools, especially when integrated into a single platform, has increased over the past year as healthcare organizations try to maximize reimbursements to counter revenue shortfalls and rapidly changing regulations associated with COVID-19.



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