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The Healthcare Revenue Integrity Principles

The Healthcare Revenue Integrity Principles

Healthcare revenue integrity seems to be a universal buzzword these days. However, it is more than just a buzzword in the healthcare industry; it is a way of conducting business and a key differentiator between successful and unsuccessful businesses.

What exactly is this concept called “revenue integrity,” and why is it creating so much buzz? It’s a word with a wide range of interpretations.

However, nearly all businesses agree that revenue integrity implies adhering to policies and procedures that uphold the highest standards of ethics in order to maximize operational efficiency, legal compliance, and payment for work actually performed. All three should be at the forefront of any organization’s approach and should function in tandem.

What Is Revenue Integrity?

Using systems and procedures that prioritize efficiency, compliance, and optimal reimbursement for services, revenue integrity in healthcare guarantees that all clinical encounters between providers and patients result in revenue. Delivered goods and services are matched with invoiced costs as part of RCM. Accurately and efficiently recording all payments due is essential.

A 2017 poll by the Healthcare Financial Management Association and Navigant Consulting found that maintaining correct coding and charge capture, charging fair prices for services rendered, and staying in compliance with applicable rules and regulations are all dependent on revenue integrity.

Companies that aren’t prioritizing revenue integrity should start doing so. Nearly one-quarter (22%) of 125 hospital & health system CFOs and revenue executives in the same HFMA/Navigant poll named revenue integrity as a major priority. However, only 44% of respondents reported that their companies have formalized programs.

Why Is Revenue Integrity Important?

Payment in a timely manner once a service or product has been provided is essential to the success of any firm. It is more challenging to compete if every day’s work is not fully compensated.

The term “leakage” is used to describe the shortfall between the amount that should be paid and the amount that is actually captured. It’s a fitting analogy: think of how cold it would be if a clinic turned on its heater during a cold spell but then discovered that some unheated rooms had left their windows or doors open.

Lastly, revenue integrity helps providers focus on service delivery and successful outcomes with fewer distractions.

How To Achieve Revenue Integrity

While it’s helpful to understand what revenue integrity is and why it’s crucial, the real challenge for most businesses is figuring out how to actually implement it.

First, everyone in the company needs to support the program for it to be a success. The success of any revenue integrity program depends on openness and communication. For healthcare facilities to function effectively, they require fair payment for their services. To protect their revenue, they must follow the rules set forth by the law and their contracts.

Integrity in revenue collection also necessitates a fair distribution of focus between revenue growth and regulation observance. Keeping up with legal and contractual compliance is challenging since the law and contracts are always evolving.

Some of the more tangible benefits of promoting revenue integrity inside your firm are as follows:

  • Mitigating the potential danger of audits from other sources.
  • Aiding in decreasing the number of denied payments.

Each of these reduces costs and frees up resources for the business as a whole. Which path should one take to reach the destination? The objective is to maximize earned reimbursement while maintaining ethical business practices and regulatory compliance. HFMA states that in order to achieve revenue integrity, one must have the appropriate processes, tools, and skills.

Revenue Integrity Best Practices

The first thing to do when prioritizing revenue integrity is to make a plan. This includes the establishment of regulations and protocols that must be followed by all revenue-related personnel. Integrity in revenue collection requires a judicious weighing of revenue growth and legal compliance. Creating a RI strategy entails the following steps:

  1. Access Current Workflows

Assess the whole process, beginning with operations and ending with invoicing that affects revenue integrity. In particular, the claims workflow needs to be checked to make sure it is effective and up to code.

  1. Implement Improvements

After performing a comprehensive audit of processes, think about what aspects could be enhanced and how resources should be divided. Verify that vital operations, including usage review, coding, charge capture, and claim editing, are running smoothly and effectively. If they aren’t, investigate why and fix the problem, so everything runs smoothly.

  1. Managing Denied Claims

It’s common knowledge that claims that are wrongfully denied lead to lost money. Confirm that denied claims are being handled in a timely and accurate manner by ensuring the denial management procedure is effective.

  1. Upgrade Technology

It’s easy to keep on without understanding that an outmoded approach is bogging things down in an era where both technology and business automation are rapidly progressing. Providers may be able to identify areas for improvement in the hospital’s usage of technology by taking a critical look at it.

How Can You Preserve The Integrity Of A Revenue

All the new variables in the system necessitate ongoing monitoring and tweaks, as is the case with any kind of process of improvement. Changes in personnel, rules and regulations, billing practices. Patient care, operational procedures, and simple human mistakes all fall under this category. Leakage rates may reduce significantly after deploying an RCM or revenue integrity system, but the work is never done.

In fact, consistent and subsequent reductions in leakage, no matter how slight, are a good indicator of the system’s integrity. Closing doors and windows will have a big impact, just like in our “drafty practice” analogy, but sometimes the smallest changes can have the biggest impact, like installing insulation.


The use of technology is becoming increasingly important for businesses to keep their processes in line with their revenue integrity objectives. The time saved by implementing automated RCM solutions, for instance, can be better spent caring for patients. In order to reduce claims rejections, automated scanning can help employees examine code before filing.

You can gain a deeper understanding of your billing process and any potential problems with Medicare claims and follow-up work with the help of automated. Comprehensive reporting and analytics. Lastly, preventing reimbursement concerns from the start by checking eligibility in real-time directly from the Medicare system.

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