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Revenue Integrity and Payment Integrity Goals Share More Than Meets the Eye

By Ritesh Ramesh

The payer/provider relationship is often seen as adversarial, with delays and denials by insurers taking the blame for falling hospital revenues. But these supposed antagonists are closer than they would initially appear.

For providers, the goal of revenue integrity is to take great care of patients, maximize the reimbursement to which they’re legitimately entitled, create operational efficiencies, and maintain regulatory compliance. Contrast that with payment integrity on the payer side, the goals of which include enabling a great beneficiary experience, member retention, payment accuracy, operational efficiencies, and maintaining compliance.

In each scenario, efficiency and regulatory compliance are directly shared. Both sides also want to empower patients/members while ensuring proper reimbursement. Accountability is key, so savvy payers and providers are looking to bridge the historical divide between them to create mutually beneficial partnerships.

Getting It Right the First Time
Shared goals can be difficult to discern at first. Payers sometimes require prior authorizations for treatment that can frustrate providers, and payers sometimes are held accountable for a negative patient experience due to payment and financial issues that come from providers.

When patients have questions about a bill or dispute a charge, they often don’t know where to turn and find themselves stuck between payers and providers—a situation that benefits no one. Payers can only compare what was charged against the contract to ensure the reimbursement was accurate. A deeper dive would be possible during an audit, but that would not occur for routine patient questions.

So the patient contacts the provider. Many billing departments keep bankers’ hours and are notoriously difficult to connect with. Billers likely cannot provide the necessary context for questions about visits or procedures, further frustrating the patient. The billing department may need to check with coders who have access to patient charts, adding time to any query and taking billers and coders away from their day-to-day duties.

By getting a claim right the first time—without under- or overcoding—a provider can maximize revenue in a shorter time frame and ensure that the patient experience is delightful when it comes to their financial commitments. Providers shore up their own financial health in the process.

Internal Scrutiny Can Prevent Costly Audits
While individual patient questions can disrupt normal activities, the specter of an audit is a significantly higher concern.

As federal payers have increased efforts to ensure the accuracy of claims, payers and providers share the goal of identifying and eliminating billing risks. Including medical review, Medicare program integrity activities return $8 for each $1 spent. In the current fiscal year, the Health Care Fraud and Abuse Control Program and the Medicaid Integrity Program are receiving nearly $2.5 billion—an $80 million increase from FY2022—for their fraud reduction activities.

Further, CMS finalized a new rule in January allowing audits to be conducted back to 2018—a change that’s expected to claw back $4.7 billion from Medicare Advantage plans over the next decade. The main area of contention centers on upcoding enrolled beneficiaries to make it appear they are sicker or require more intense treatment than their medical records support. The Office of Inspector General has conducted dozens of audits of most large Medicare Advantage plans, finding $461 million in upcoded charges in the past two years alone. Overcoding could account for as much as 7% of all Part C payments, according to the Office of Inspector General.

Payers have a fiduciary responsibility to their clients to ensure that beneficiary claims are paid accurately. The federal Employee Retirement Income Security Act of 1974 sets minimum standards for most private industry retirement and health plans to protect those participating in these plans.

Under price transparency rules, hospitals are required to publish prices for certain procedures that payers can check against their contracted and published chargemaster rates to ensure they’re not overpaying for the care of their members.

Providers also can face audits. Overcoding or improper coding, such as more charges for visits and procedures than one physician could reasonably perform in a day, can result in an audit that could create negative headlines and a damaged reputation for a provider or a health system.

A payer-provider partnership that promotes both payment integrity and revenue integrity can bring better patient satisfaction while reducing the chance for a costly audit. Technology platforms and data analytics can play a critical role in this process of being proactive to catch and fix issues before they occur.

Focus on Enabling Faster Payments to Drive Cash Flow
Billing and claims processes are dynamic, constantly in flux due to new payer contracts, updated guidance, new/amended codes, internal findings and education, and other factors.

Billing compliance and revenue integrity leaders at the provider organizations in this macroeconomic environment must assess and make investments to use technology and data analytics to monitor claims sooner in the adjudication process to catch errors to accelerate cash flow. Don’t be satisfied with the claims being eventually paid but focus on how fast it can be paid. Similar technology deployed by payers can serve as an important check on providers while monitoring adherence to applicable regulations.

When payment integrity and revenue integrity are considered complementary—not competing—processes, both payers and providers benefit through shared goals and collaboration to ensure providers are paid appropriately and promptly and payers are maintaining compliance and not overpaying claims.

— Ritesh Ramesh is CEO of MDaudit, a leading health IT company that harnesses its proven track record and the power of analytics to allow the nation’s premier health care organizations to mitigate compliance risk and retain revenue.