Revenue Integrity in Healthcare: Best Practices for MSOs and Physician Groups

How long was it before you realized revenue integrity (RI) was not the same thing as revenue cycle optimization? 

As a finance professional in a healthcare management services organization (MSO) or a physician group, most likely you’re still working toward overall revenue cycle optimization. You’ve found the root causes of your revenue leakage (often underpayments and denials, but upfront patient payments, too), and are developing new workflows and even new technology to address those. You’re in good company. A survey of healthcare leaders by MGMA found that over 70% cite revenue cycle efficiency as a top priority for their organizations.   

Don’t forget, however, that revenue integrity, a subset of revenue cycle optimization, plays a significant role in improved revenue capture and reductions in costs to collect. 

Today, it’s most often large hospitals and health system networks that have the budget for a robust revenue integrity program. 

However, at the rate that MSOs and physician groups are growing (with a 20% jump in M&A activity forecasted to occur in 2025), you, too, can – and should – dive into the revenue integrity waters. 

Healthcare facilities that implement technological advances in revenue integrity enjoy advantages. A survey by the Healthcare Financial Management Association of hospital revenue cycle professionals found that healthcare leaders report that a dedicated revenue integrity department or specialist resulted in: 

• 68% of respondents claiming an increased overall net collection  
• 61% claiming increased gross revenue capture 
• 61% claiming decreased compliance risks

While the research covered here mostly involves hospitals (people have not analyzed smaller operations yet), their insights provide a path for MSOs and physician groups to develop or improve their own revenue integrity programs.   

Here, you can review exactly how revenue integrity fits in with revenue cycle optimization and just how your organization can achieve gains like these. 

What is Revenue Integrity

Revenue integrity (RI) is a focused approach that accurately documents, codes, bills, and reimburses healthcare services. Its primary objectives include preventing revenue leakage and managing compliance risks through meticulous processes and robust internal controls. This discipline concentrates on precise charge capture, coding compliance, and comprehensive auditing to guarantee the financial accuracy of healthcare services pricing and reimbursements.

Revenue integrity vs. revenue cycle optimization

Healthcare professionals sometimes confuse revenue integrity and revenue cycle optimization. While the two finance concepts are related, they are not identical. Revenue integrity is a component of the broader revenue cycle optimization strategy. 

Revenue cycle optimization encompasses tasks like eligibility and denials on the front end, scheduling, prior authorization, charge capture in midcycle, and – on the backend – A/R, denials management, and collections. Revenue integrity, on the other hand, sticks with the accurate documentation, coding, billing, and reimbursement of services proposed or rendered. 

Revenue cycle optimization includes revenue integrity efforts. 

Healthcare organizations seeking optimal financial performance typically combine revenue integrity practices and broader revenue cycle optimization approaches. This combination allows healthcare providers to maximize appropriate reimbursement, maintain strict regulatory compliance, and achieve superior operational efficiency in an increasingly complex healthcare financial landscape.

A revenue integrity program’s operational improvements

Those who implement a revenue integrity department or bring on an RI specialist find:

• fewer claims requiring manual intervention
• reduced claim denials
• fewer repetitive claim edits and denials due to tracking and correction
• more accurate charge-capture
• streamlined billing processes
• improved workflow across the revenue cycle

• more accurate reimbursement through proper coding and billing practices
• increased compliance with complex regulatory requirements, reducing the risk of audits, penalties, and recoupments
• better access to the data to support appropriate scaling
• Improved clinical documentation
• missing charge identification
• more accurate coding 
• better compliance with coding changes and regulations

Clearly, a revenue integrity program or specialist can significantly contribute to a healthcare organization's overall financial health and operational efficiency.

Two departments, then?

Having both a revenue integrity department (or manager/specialist) and a revenue cycle department can provide several advantages for healthcare organizations. First, each department can focus on its specific area of responsibility, allowing them to develop deep expertise in their respective fields. Specialization improves accuracy and efficiency.

Additionally, having both departments ensures comprehensive coverage of all aspects of revenue management. The revenue integrity department can concentrate on detailed pricing and charge accuracy, while the revenue cycle department oversees the broader operational processes like workflows, prior authorizations, claims, and denials management, and communication across departments. Collaboration creates a robust system that can illuminate potential gaps in revenue capture and management.

Consider too that the relationship between the two departments fosters checks and balances within the organization. They can work together to identify and resolve issues that might be overlooked if only one department were responsible for the entire revenue process. Collaboration enhances compliance, as the revenue integrity team's focus on accuracy and adherence to regulations complements the revenue cycle's operational oversight.

Finally, the combined efforts of both departments can lead to improved financial performance. By working together, they can optimize revenue capture, reduce denials, and enhance overall cash flow. Overall, having both revenue integrity and revenue cycle departments (or executives/managers) is something growing MSOs and physician groups should seriously consider.  

Dividing revenue cycle management and revenue integrity tasks

Revenue cycle management departments and revenue integrity departments have overlapping but distinct focuses within healthcare organizations:

The revenue cycle management department: 

• oversees the entire revenue cycle from patient scheduling through final payment collection.
• focuses on the overall financial processes and workflows to ensure the organization receives payment for services rendered.
• manages the day-to-day operations of billing and collections.

The revenue integrity department:

• concentrates specifically on ensuring accuracy and completeness of revenue capture.
• focuses on preventing revenue leakage and compliance risks.
• conducts audits to scrutinize billing, coding, and documentation processes for accuracy and compliance.
• monitors key revenue indicators and metrics to detect irregularities promptly.
• emphasizes the accuracy of charge capture, coding, and regulatory compliance.
• acts as a bridge between clinical operations and financial processes.

While there is some overlap, the key difference is that revenue integrity departments prioritize accuracy, compliance, and preventing revenue leakage, while RCM departments manage the broader operational aspects of the entire revenue cycle.

 Revenue integrity professionals’ key responsibilities

Your revenue integrity program or executives and professionals must take on these responsibilities:  

1. Chargemaster maintenance (81%) - review guidance on strengthening the healthcare chargemaster in depth. Review how to optimize your chargemaster as well.

2. Price strategies/methodologies (59%) 

3. Charge edits (56%) 

4. Charge capture (55%)

5. Price transparency compliance (48%) 

Along with their core primary functions, revenue integrity programs support RCM tasks. These tasks leverage the revenue integrity program’s strengths.  

1. Educating revenue cycle/nonclinical staff (55%)

 2. Charge reconciliation (52%) 

3. Denials management (52%) 

4. Claim edits (50%)

5. Coding edits (hospital and/or professional fee) (46%)

How to start a revenue integrity department

Because revenue integrity is a fairly new discipline, standardized education and resources are difficult to find. All effective revenue integrity programs monitor and analyze trends in billing edits and charge captures, compliance auditing, and ongoing education.

Perform a current-state assessment

Assessing your current state will provide a road map for building your RI program and a baseline to measure progress. 

Start by dedicating a point person to lead your efforts. A revenue integrity department manager or specialist should have expertise in compliance, clinical documentation, coding, and a strong understanding of the relationship between codes and revenue in reimbursement.

Your initial assessment should list all essential revenue integrity functions. Document the staff assigned to perform each function, the departments that oversee the staff, and the resources allocated to that function. This rubric will help you see which functions can be consolidated, which need more resources, and which are missing.

Build your team

While smaller practices may be able to get by with one person serving as the revenue integrity specialist, keep in mind that revenue integrity is complex. As you build your team, look for those with expertise and skills in:

• quality assurance
• data analytics
• regulatory guidelines and changes
• clinical operations
• billing workflows
• internal auditing
• interdepartmental communication

Creating a team with a broad skill set in revenue opportunity and risk will help break down the silos in your organization and ensure alignment of all revenue-generating departments. With a centralized flow of information, it's easier to root out and address common themes.

Your newly formed RI department may require a restructuring of established teams. The functions you identified in your list will now fall under the purview of the revenue integrity department. 

Establish an action plan

Although your initial revenue integrity functions will be based on your initial assessment, a value-generating RI department will continuously monitor, assess, and improve. Effective communication across various departments is necessary for a successful RI initiative. 

Your RI department will generate a tremendous amount of data, so the first step in effective communication is narrowing down the message. Identify the top three or four issues that will have the most impact based on audit results, charge data, and remit data.

Based on this data, identify improvement opportunities in revenue opportunities, billing anomalies, or coding risks. Communicate these priorities to the billing and revenue cycle management. 

Measure improvement

You'll know if your revenue integrity strategy is on the right track when your data compares favorably to industry benchmarks. 

Review these healthcare RCM benchmarks to understand whether your performance meets industry standards and if there are patterns that need further exploration.

Benchmarking will help you find opportunities for increasing revenue, identify risks associated with under- or over-coding, and share insights with other departments. Comprehensive benchmarks should compare your current performance to your historical performance and industry standards. 

When you find discrepancies, work to uncover the root cause. Slicing your results by provider, coder, specialty, or facility can provide clues to the dysfunction or bottleneck. Once you discover the underlying issue, develop new workflows to rectify it. You can significantly increase revenue and decrease compliance risks through repeated education and auditing cycles.

The five best practices for revenue integrity in 2023

Revenue integrity can always be improved. Start on the areas that have the biggest impact. These five best practices will guide you.

Automating denial and underpayment management

Given the RCM labor shortage and the soaring costs of revenue specialists, many healthcare organizations are using software solutions to automate denial and underpayment detection. Automating processes should include predenial management, postdenial management, and insightful reporting. 

Take a quick, self-guided tour through a powerful contract management and underpayments identification tool that automatically alerts you to payment variances:

Pre-denial management

Pre-denial management begins with automating workflows that ensure all typical causes for denials have been accounted for and routed to corrective action. This includes corrective workflows such as:

• duplicate billing errors
• incorrect patient demographics
• missing patient information
• incorrect CPT modifiers
• preauthorization where required
• verifying insurance eligibility

Post-denial management

After denial, you can prioritize recovery efforts and minimize future denials by automating the following workflows:

• prioritize denials by data to avoid late claim denials
• sort denials to determine which represent the best opportunity for quick revenue recovery
• bulk appeal denials with the same payer and the same cause of denial
• route complex bills into separate review processes by trained billing managers

Reporting insights

Data analytics from your automated denial and underpayment management system can give you actionable steps to reduce denials in the future by identifying problems within your claims process. High-level analysis will:

• uncover trends in denials
• allow you to easily share your findings with front and middle-state revenue cycle teams to eliminate denials caused by processes upstream
• establish metrics to assess productivity

Have an ironclad audit process with strong documentation

One of your RI department's top priorities should be implementing a thorough auditing process backed by comprehensive documentation. Internal audits are a vital part of ensuring both compliance and optimal reimbursement.

Your auditing process should begin by focusing on high-risk and high-value areas. Improvements in these areas will generate the greatest return by improving patient satisfaction, reducing compliance risks, and increasing revenue.

Identify risk profile

Your first step in developing a strong auditing process will be identifying your risk profile. Your best option for identifying risk is the same data the government uses to detect fraud. If government agencies are scraping claim data to detect fraud, you should analyze your organization's claim data for the same patterns.

Your risk profile should provide specific, targeted areas of concern, such as write-off procedures, bad debt, or the aggressive resolution of denied claims. Once you've identified your risk profile, start the auditing process on the area of highest risk or highest value.

Design your audit

Your internal audit should include at least the following three elements.

Review process flow and design. Walk through each step of a transaction to determine if it's as efficient as possible. Analyze key controls to determine if they effectively mitigate risk or if there are blind spots you need to change. This should be a hands-on process rather than a review of established procedures so you can find any friction points where actual practice differs from the policy.

Data analysis and benchmarking. Standard KPIs for similar organizations provide a good starting point for measuring your performance. These metrics will help you focus on areas that are out of alignment with industry standards and are ripe for review. Some examples include:

• Number of claims delayed by edits
• Payment variances
• Denial backlog
• Missed filing deadlines

Regulatory compliance. Compliance risks should always be part of every audit. You'll need to ensure that any changes you make to your workflows don't trigger integrity issues.

How contract management software supports revenue integrity

Contract management software provides revenue integrity teams with the tools and information needed to maximize revenue capture, improve compliance, and optimize the entire revenue cycle process. 

1. Improved visibility and access:

• provides a centralized repository for all payer contracts
• enables quick access to specific contract terms, fee schedules, and reimbursement models
• allows revenue integrity teams to easily reference contract details when reviewing claims or addressing denials

2. Automated contract analysis:

• analyzes contract terms and clauses to surface relevant insights and risks
• identifies discrepancies between contracted rates and actual reimbursements
• flags potential underpayments or non-compliance with contract terms

3. Integration with revenue cycle management systems:

• sends payer contract data directly to RCM systems for a holistic view of terms and conditions
• helps maximize revenue opportunities by ensuring claims align with contract terms
• reduces unnecessary claim denials by providing up-to-date contract information

4. Advanced analytics and reporting:

• provides dashboards to compare terms across payers
• offers insights into how contract changes impact reimbursement, risk levels, and performance
• enables data-driven contract negotiations with payers

5. Charge capture optimization:

• ensures charges align with contracted rates and terms
• identifies missing charges or potential areas of revenue leakage
• supports accurate and compliant billing practices

6. Compliance management:

• tracks regulatory requirements and contract obligations
• alerts teams to upcoming contract renewals or changes in regulations
• helps maintain compliance with complex healthcare regulations

7. Forecasting and modeling:

• allows for predictive contract modeling to assess the financial impact of proposed contract changes
• supports strategic decision-making in payer negotiations

8. Streamlined workflows:

• automates manual processes related to contract management
• reduces time spent searching for contract information
• improves the efficiency of revenue integrity teams

Implement revenue integrity best practices at your MSO or physician group  

Revenue integrity programs can help healthcare practices and facilities maximize revenue, reduce risk exposure, and improve patient satisfaction. Because revenue integrity is a complicated endeavor with multiple stages, choosing the right tool for implementation is critical. Starting with an accurate, comprehensive solution will help you avoid problems with your revenue integrity functions down the line.

MD Clarity’s RevFind provides visibility into the entire revenue cycle and allows you to create action plans based on high-level data. You'll gain insights into how your revenue-generating departments are performing. Automation improves staff productivity and reduces errors. In one suite of tools, you can detect underpayments from health plans, model proposed payer changes, and track the performance of payer contracts.

Whether you're just launching your revenue integrity program or looking to improve existing efforts, MD Clarity can improve your financial performance and allow you to build trust with your patients through a transparent experience.

Schedule a demo to see how RevFind can help your revenue integrity program or specialist find your missing revenue. 

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