Revenue Integrity, Silo or Solution?

In clinical revenue cycle there are several components that tend to function in silos:

• Utilization Review
• Case Management
• Clinical Documentation Integrity
• Physician Advisor
• Coding

Looking at this from a holistic approach it is important to remember that no one component is more important than the whole. There is one factor that ties these components together and that is documentation, the medical record. All are looking at the same documentation but through their own lenses, thus creating silos with very little communication amongst them, sometimes resulting in turf wars. “The silo mentality can be defined as a mind-set present when certain departments or sectors do not wish to share information with others in the same organization. This type of mentality will reduce efficiency in the overall operation, reduce trust and morale, and may contribute to the demise of a productive company culture.”[1]

Silos are not unique to the healthcare industry, as they exist everywhere. Silos are a form of territorialism and “people who ‘mark their territory’ do so as a protective mechanism. By being territorial, it gives them a sense of control or perceived power over others. These territorial behaviors may stem from an inner insecurity or experience where they didn’t have control in their past.”[2] Silo thinking is also not an adult learned trait. It is actually engrained in our thinking from early life. High school is a perfect example – one school, but a different teacher, classroom, for each topic. Each teacher has their own subject to teach, they don’t communicate with the other courses or connect them. They have their own testing, methods of grading, etc., perfect example of developing silos. If that is what we grew up with and unknowingly exposed to that kind of thinking, why would we not take that principle forward into our adult and business lives.

One of the keys to success in revenue cycle is to breakdown these silos, thus producing collaboration, communication, an aligned vision, standardization, and accountability with significant potential sustainable revenue preservation.

While viewing a television program the other day, “Impossible Engineering”[3], there was a segment on literally breaking down a silo using implosion (Implosion is a process in which objects are destroyed by collapsing (or being squeezed in) on themselves.[4]) techniques. When one thinks of a silo, typically a farm setting comes to mind. In this show a comment was made that silos are strong structures based on how they are constructed, and implosions can be disastrous even with proper techniques. Because of their methods of construction, according to this show, they really need to be taken down piece by piece. With this reality analogy, it makes sense that breaking down these silos in revenue cycle cannot be done with an implosion technique, they are strong. A piece by piece breakdown needs to be employed.

With a silo mind-set present, as mentioned above, involved departments or sectors do not wish or think to share information with departments in the same organization. Take law enforcement as an example: does local, state, and FBI share all the information with each other? This thinking is quite prevalent in clinical revenue cycle potentially resulting in numerous process and technical errors.

It seems that there is now a relatively new concept or program that has come into play and it is called “Revenue Integrity” (RI). Is it another silo or is it a solution for clinical revenue cycle? According to an HFMA Survey of 125 hospital and health system CFOs and revenue executives, only 44 percent of respondents say their organizations have established revenue integrity programs. This forward-thinking group has benefited significantly. The result of these revenue integrity programs has been a 68 percent increase in net collection, 61 percent overall gross revenue capture and 61 percent reduction in compliance risk.[5]

Interestingly, 22% of respondents identified RI as the leading priority for their organizations, but fewer than half of them (44%) have established RI programs. For those healthcare systems that have developed RI programs, the results are significant. More than 68% of executives surveyed reported increased net revenue collections, with 61% reporting an increase in gross revenue collection. In addition, 61% reported a decrease in compliance risk after establishing a RI program.

What is revenue integrity? In a conversation with an individual that comes from an organization that utilizes this concept, she described it as a process of proactive audits looking for accurate charges at the point of care resulting in a prevention of revenue leakage. But there is more to it than that. Additional results can be improved revenue capture, reduction of accounts receivable days, improvement of documentation and charge redundancy, charge process efficiency, responses to third-party charge audit requests, billing system edit resolution, and workflow optimization. A central goal of any program will be the development of appropriate clinical and operational workflows producing correct charge capture the first time, a process of prevention, not correction. It can be useful to think of revenue integrity as leading to continuous improvement.

Individual integrity means doing the right thing even when no one is watching, being honest and morally upright. even with decisions and actions that may not serve one’s personal interests. Organizational integrity is the same on a larger spectrum. It has a codified approach to establishing and supporting ethical business practices that compel all associates to do the right thing in a variety of situations. In the healthcare industry, there is a concern to achieve sustainable revenue. A hospital that institutionalizes revenue integrity has likely developed a set of policies and procedures that compel all to do the right thing. Specifically, in the mid-revenue cycle, that means claims that maximize legitimate reimbursement. The processes and tools used to support revenue integrity include workflow optimization, compliance, clinical documentation improvement, data analytics, business intelligence, and, most important, teamwork.

In order for this process to be successful there must be agreement amongst stakeholders from all areas of the organization.  There may be many stakeholders, but the main players are:

• Quality
• Compliance
• Coding
• CFO
• Physicians[6]

Remember that the center of all that is done in healthcare is the patient. It starts and ends with quality – the quality of the patient experience including outcomes, and acuity accurately reflected in the final bill. This must be supported by appropriate documentation telling the patient’s story without embellishment for reimbursement gains. That tends to increase scrutiny and denials.

We are all well aware that there are a plethora of rules and regulations in the healthcare industry. A goal of revenue integrity should be compliance with these regulations keeping in mind the False Claims Act on the federal side which states that ALL claims submitted must be compliant. This integrity is aided with correct coding and charge capture at the point of care with a resultant reduction of audits and clawbacks from payers.

Coding is pretty much the final step in claim submission, of course before scrubbers and clearing houses. It is critical that coding does not operate in a silo (remember the definition of silo thinking above) but work collaborative with CDI and even UR. It is also very important that there is sufficient documentation to support the codes that are utilized. Recently it seems that patients are made to look sicker than they really are and that will lead to denials and compliance risks. Revenue integrity can play a major role in this area.

One may think that the CFO is the most important stakeholder in revenue integrity, by virtue of his or her position. I don’t believe so, but they should have the responsibility for allocating the resources and processes so that other teams, stakeholders, can perform their roles successfully. CFO’s need to remove bottlenecks, constraints for the teams, discouraging workarounds, optimizing the workflows between these often-divided areas. They can develop dashboards to monitor an accurate representation of what level of revenue integrity is being achieved, what opportunities exist in terms of addressing it, and the respective impact of each of the activities and results for the teams to see.

Lastly, is the physician and it is quite simple. They are responsible for documentation, documentation, documentation.

In conclusion, establishing a Revenue Integrity program will improve workflows and simultaneously create a necessary knowledge base inside the organization to help medical coding and revenue cycle professionals operate more effectively. These programs will typically act as a bridge between clinical, coding, and other mid revenue cycle components. The goal is to help provide front-end corrective solutions instead of back-end corrections that are time-consuming and costly.

Remember that integrity is doing the right thing, even when no one is watching using a codified approach to establishing and supporting ethical business practices. By ensuring that the integrity of coding and billing is accomplished by team members with their various skill sets and expertise, they can smoothly adapt to the workflows of each of these separate functions. These teams are typically comprised of various skillsets, registered nurses, and coders who are able to validate that the patient’s condition and subsequent care delivered are properly coded and charged.

Revenue integrity is evolving into its own space. Again, one must decide and plan whether is it another silo or is it a solution towards collaboration, standardization, accountability, and communication, leading to knowledge and process sharing solutions to improve existing elements of revenue cycle. It will involve improvements across three areas in order to lessen compliance risk and increase sustainable revenue:

1. Process
2. People
3. Platforms

Maintaining your hospital’s mission means achieving margins and doing so in compliance, and providers can turn to revenue integrity to help accomplish outcomes. Balancing the drive to increase revenue with the imperative to comply with rules is the essence of revenue integrity.[7],[8]

[1] https://www.inc.com/brent-gleeson/5-ways-to-destroy-the-pesky-silos-in-your-organization.html

[2] https://healthyworkforceinstitute.com/using-curiosity-to-deal-with-a-territorial-coworker/#:~:text=People%20who%20“mark%20their%20territory”%20do%20so%20as,where%20they%20didn’t%20have%20control%20in%20their%20past

[3] https://press.discovery.com/us/sci/programs/deadly-engineering-and-impossible-engineering/#:~:text=IMPOSSIBLE%20ENGINEERING%20is%20produced%20by%20Twofour%20Broadcast%20for,producer%20and%20Lindsey%20Foster%20Blumberg%20is%20supervising%20producer.

[4] https://en.wikipedia.org/wiki/Implosion_(mechanical_process)

[5] The Future of the Revenue Cycle, HFMA Magazine, June 2017

[6] https://streamlinehealth.net/HIM-blog/revenue-integrity-can-organization-best-achieve/

[7] https://www.hfma.org/topics/revenue-cycle/article/revenue-integrity—minding-the-gaps-between-clinical-operations.html

[8] https://parallon.com/insights/what-revenue-integrity