Clinical Revenue Integrity

What is clinical revenue integrity?

As health care moves from fee-for-service to value-based payment, organizations must have the ability to connect cost with clinical outcomes. Clinical revenue integrity is essential for each individual patient and across entire care populations. It prevents the recurrence of issues that create risk for revenue, for patients and for the healthcare provider organization. “Revenue integrity means right revenue, right delivery, and right protocols to ensure right [accurate] reimbursement and compliance. Revenue integrity doesn’t begin with a charge.” – Suzanne Lestina, revenue cycle technical director for the Healthcare Financial Management Association (HFMA).

Clinical revenue integrity is:

  • Process efficiency – people and technology
  • Compliance – following rules of engagement
  • Correct payment – proper pricing, charging, coding and documentation

Clinical revenue integrity programs

Clinical revenue integrity (CRI) incorporates the entire healthcare organization and ensures all stakeholders—CDI, case management, HIM, quality, etc—understand their role and technology’s role. When CRI programs are appropriately designed and implemented, organizations can expect a higher clean claim rate, proactive identification and resolution of patient care issues, and improved quality reporting results. CRI begins with clinical documentation and coding integrity (CDCI), and CDCI begins with R1.

 nSight-Driven Workflow for Clinical Revenue Integrity

 

What does it mean to be nSight-driven in health care? RecordsOne defines nSight-driven as getting usable and meaningful clinical information to users when, where and how they need it.

Why is that important? Consider this: when a patient is admitted, how many different staff need to be aware of that single admission? CDI? Case Management? Quality? Research? Obviously, it can vary a great deal based upon the reason for the admission, as well as many other contributing and historical factors.

Many believe that Natural Language Processing (NLP) is the ‘key’ to uncovering the ‘hidden gems’… not exactly. Clinical revenue integrity takes the right combination of technologies to truly create nSight-driven workflow. NLP is but one component of a sophisticated set of tools that creates an optimal ‘nSight-driven workflow’.

Clinical revenue integrity incorporates the entire healthcare organization and ensures all stakeholders—CDI, case management, HIM, quality, etc—understand their role and technology’s role. NLP technology enables data capture, but stakeholders enable its effectiveness. If clinicians don’t uphold clinical documentation, cases cannot be coded correctly—missed documentation could mean missed revenue.

The Growing Clinician Role in Revenue Integrity As hospitals and health systems face tightening margins, increased regulatory review, and a shift toward value-based payment, many find clinicians playing a greater role in revenue integrity initiatives. With this in mind, this HFMA Executive Roundtable, sponsored by Adreima, focuses on ways healthcare finance executives can work with clinicians to improve revenue integrity and how to best position these initiatives for success.