1. Revenue Integrity
Getting Started

2. Let’s Get Started! Evaluate current state
Start with an open mind and a conviction that things can be better

3. What Is Revenue Integrity?
Quality Officer – Patient experience, proper requested reimbursement
Coding Director – documented. education, support, CDI
Compliance Officer – up to date adherence to all laws and regulations
Providers – Accurate documentation, timely submission, effective communication with coders
Revenue Integrity analyst team
CFO – support for resource allocation
All of this is on slide 5 RI… is this restatement necessary??

4. First Steps Identify each function Current positions
Staffing/resources involved

5. Revenue Integrity Who will oversee/what position Who will manage
What should the team look like
Create organizational chart

6. Expectations Define the expectations of Revenue Integrity
These are not billing
Not compliance
Not IT
This team is billing and reimbursement compliance through responsible maximization of technology

7. Getting Started Outline
Create a definition, expectation, mission statement
Outline
Short term goals
Long term goals
Timelines
Define roles

8. RI Manager Program Leader
Experience with reviewing coding, documentation, regulatory changes
Understands CPT, HCPCS, Modifiers and other claim elements
Expert in the relationship between Codes, claim submission, revenue and reimbursement
Strength addressing compliance issues, and adhering to regulatory expectations
Payor agreements, policies, manuals
Experience with contract management – understand that what we bill is not what we get paid
How a bill becomes a law
Robert Downey Junior image by Mayank.naruto (i Clicked it at comic-con) [GFDL ( or CC BY-SA 3.0 ( via Wikimedia Commons

9. The Team – Revenue Integrity Analysts
Revenue Integrity Analysts – strong Revenue Cycle skills with strong understanding of billing and reimbursement
Government and commercial payors,
LCDs (Local Coverage Determinations)
Payor Policies and Newsletters
Medicare Administrative Contractor (MAC) and probe audits conducted by MAC
Skilled in payment methodologies
Bundling and packaging – including proper modifier assignment
Comprehensive and Composite packaging
Skilled in documentation and Documentation Review
Nurses
CDI

10. Technology Maximize existing tools or consider adding essential tools
Contract management
Auditing
Front end POS tools
The technology should be the adjunct, not the driver
NLP documentation should be reviewed and audited
Coding tools reviewed and audited
CDI
Many facilities gain a false sense of security as a result of the latest, greatest technology…

11. Audit Categories - Departmental
Inpatient and Outpatient
Charges
Charge capture rates
Lag days
Late charges
Pharmacy
Inpatient and outpatient
Meds returned to stock
CDM Maintenance
How many charge codes with no CPT or unlisted CPT
Multiplier maintenance
Supply chain
Understanding of revenue code assignment
Billable and non billable
Markup up
Supply policy

12. Charge Capture Total charge validation processes
Reconcile activities vs. accounts
Surveys indicate facilities lose, on average, 1% due to charge capture inefficiencies
Chart audits
Charge capture solutions
Tools and technology

13. Education Develop education based on Audits Edits Patient complaints
Payor findings
Create training and education expectation for RI team
Remain current in regulatory, industry changes
Coding, CPT modifier changes
Orientation tools
Instructional materials
Payor website resources
Position specific training

14. Develop Best Practices - Processes
Continuous Improvement
Follow- up
Education
Implementation of improvement plan
Identification of issues
Review

15. Useful Links
risk-adjustment-methodology.pdf