The Wilshire Group Blog

Home | The Wilshire Group Blog | Redefining Revenue Integrity

Redefining Revenue Integrity

As healthcare has evolved with EHR practices, transitioning responsibilities have called for the need to re-define a fundamental discipline of the revenue cycle. Standardly, the revenue cycle is comprised of five main parts: access, charging, coding, billing and payments. When things are operating optimally, these components conspire together to submit a clear, accurate claim and receive payment in a timely manner. While EHRs have bolstered many areas of the revenue cycle with robust access options incorporating real-time eligibility and streamlined coding workflows with immediate access to much clearer documentation, it has left one area a bit discombobulated: revenue recognition.

Historically, charge capture has been either a manual process with paper tickets all over the place or a clunky interface from clinical applications. Now, with EHRs, there are a variety of options available to capture charges quicker and more accurately.

Documentation based charge capture, rule-based charging for surgeries, orderable performable chargeable linking, customizable preference lists, and shell EAPs are just a few of the features available for your clinical staff to enhance their charge capture experience. Although the available functionality for charge capture is strong, implementing it successfully can be extremely challenging. It can even cause your revenue integrity program to take a big step backwards

The reason it is difficult to implement a weighty piece of functionality is simple. The extent to which charging fits in can be vague, undefined, or confusing for organizations. What truly is the breadth of charging within an EHR? Who owns charging in an EHR, and who are the essential individuals that need to be involved to ensure charging is successful?

These responsibilities often are placed on some combination of your chargemaster and billing analysts. Thus, charging becomes one of the biggest headaches within the revenue cycle because not all the right people are involved when they should be. It’s not to say chargemasters and billing analysts don’t know what they are doing, but they are just one piece of a larger puzzle. The overlooked individuals in this whole thing is the nurse or clinician that triggers these charges and the analysts that support these clinical applications.

So, what is the true definition of the revenue integrity? The Healthcare Financial Management Association (HFMA) defines revenue integrity as “All Administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue.” The key piece of this is “All administrative and clinical functions.”

Now, knowing what revenue integrity is and knowing how to truly integrate your program with clinical expertise and application functionality are two different challenges. Changing the mindset of your organization to understand what encompasses this unique discipline in the revenue cycle and aligning these historically separated groups can be difficult. This especially holds true if your clinicians do not currently trigger their own charges or if your coding department is the primary owner of charge capture.

At Wilshire, we are experienced in changing this mindset and creating a collaborative group comprised of clinical and billing representatives to truly integrate your revenue cycle. We understand the historical mindset, and we utilize tried and true techniques and approaches to “redefine” this mindset within your organization. We know how to implement necessary processes, and how to navigate the common pain points when making this transition.
Does this sound like an issue at your organization? Do you find your clinical and billing teams pointing fingers at each other? Does it take weeks to fix an issue or create something as simple as a new charge code? Are you managing complex issues in email trails? If you answered yes to any of these questions or if you are just looking to further enhance your processes today, let us know. Let Wilshire guide you through this revenue cycle transformation and help you redefine your revenue cycle.

Over the next few months we will be detailing specific areas within the revenue cycle where you can begin taking the next steps to improve your current processes. Below are a few of the major topics we will be covering in revenue cycle integration this summer.

The Value of Accurate Charge Capture
Charge Router Pt. 1: How and When to Automate
Charge Router Pt. 2: Guidelines to Maintaining an Efficient Router
Automating Clinical Charge Capture
Handling Charge Capture for ED Coders
Coder/Clinician Communication Management