Updated on: March 4, 2021

Revenue Integrity: Silo or Solution?

By
Original story posted on: March 3, 2021

Silo thinking is also not a learned trait. It is actually engrained in our thinking from early life.

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

  • Utilization Review (UR)
  • Case Management
  • Clinical Documentation Integrity (CDI)
  • 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,” inspirational speaker Brent Gleeson wrote in Five Ways to Destroy the Pesky Silos in Your 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.”

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,” a post from the Healthy Workforce Institute read. “These territorial behaviors may stem from an inner insecurity or experience where they didn’t have control in their past.”

Silo thinking is also not a learned trait. It is actually engrained in our thinking from early life. High school is a perfect example – one school, but a different teacher and classroom for each topic. Each teacher has his or her own subject to teach, and they don’t communicate with the other courses or connect them. They have their own testing, methods of grading, etc., making this a perfect example of developing silos. If that is what we grew up with, unknowingly being 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 break down these silos, thus producing collaboration, communication, an aligned vision, standardization, and accountability, with significant potential for sustainable revenue preservation.

While viewing a television program the other day, “Impossible Engineering,” there was a segment on literally breaking down a silo using implosion: a process in which objects are destroyed by collapsing them on themselves.

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 analogy, it makes sense that breaking down these silos in revenue cycle cannot be done with an implosion technique; after all, they are strong. A piece-by-piece breakdown needs to be employed.

With a silo mindset present, as mentioned above, involved departments or sectors do not wish or think to share information with other departments in the same organization. Take law enforcement as an example: do local, state, and federal agencies share 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 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 a Healthcare Financial Management Association (HFMA) survey of 125 hospital and health system CFOs and revenue executives, only 44 percent of respondents said their organizations have established revenue integrity programs. This forward-thinking group has undoubtedly benefited significantly from them. The result of these revenue integrity programs has been a 68 percent increase in net collection, a 61 percent increase in overall gross revenue capture, and a 61 percent reduction in compliance risk.

Interestingly, 22 percent of respondents identified RI as the leading priority for their organizations, but fewer than half of them have established RI programs.

What is revenue integrity? In a conversation with an individual who 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 mitigation of 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, yet 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 goal 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, CDI, data analytics, business intelligence, and, most importantly, teamwork.

In order for this process to be successful, there must be agreement among stakeholders from all areas of the organization.  The main players are:

  • Quality
  • Compliance
  • Coding
  • CFO
  • Physicians

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 clearinghouses. It is critical that coding does not operate in a silo (remember the definition of silo thinking above), but works collaboratively 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 directing the processes so that other teams, stakeholders, can perform their roles successfully. CFOs need to remove bottlenecks and constraints for their teams, discouraging workarounds and 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 this 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 your 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 varying skill sets and expertise, they can smoothly adapt to the workflows of each of these separate functions. These teams are typically comprised of various individuals 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 whether it will be another silo – or is it a solution aimed towards collaboration, standardization, accountability, and communication, leading to knowledge and process sharing to improve existing elements of revenue cycle? This will involve improvements across three areas in order to lessen compliance risk and increase sustainable revenue:

  • Process
  • People
  • Platforms

Maintaining your hospital’s mission means achieving margins and doing so while staying in compliance; this way, 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.

John Zelem, MD

Dr. John Zelem is a board-certified surgeon-turned healthcare consultant. He is the founder of Streamline Solutions Consulting, Inc.

This email address is being protected from spambots. You need JavaScript enabled to view it.

Related Articles

  • Anatomy of Managing LOS
    LOS management is analogous to a sports team. Recently there has been a lot of posting, blogging, and articles on length of stay (LOS) and Medicare spending per beneficiary (MSPB). These are, in the opinion of many, related metrics, yet…
  • Managing Revenue Flow, Uncovering Challenges
    LOS versus MSPB—the same or different. Length of stay (LOS) and Medicare spending per beneficiary (MSPB): are they both necessary? Are they complementary, or different metrics? In pre-COVID times, revenue in general was good. Yes, there were challenges to be…
  • The New World of Auditing
    What’s next for auditing professionals? The first thing to note here is that I am not an auditor.  So, for me to write an article on auditing tips might seem a bit unusual. But this is not an article on…