Revenue Integrity Moves Center Stage in 2021: Five Trends That Will Drive Adoption of More Holistic Strategies

By Vasilios Nassiopoulos, Vice President of Platform Strategy and Innovation, Hayes

There will be little nostalgia associated with placing 2020 in rearview mirror for most health care stakeholders. Especially on the financial front, the year has left provider organizations with unprecedented challenges that will likely follow them well into 2021.

One report released in September 2020 suggested that for-profit hospitals will continue to see a financial decline for another 12—18 months. In tandem with those challenges, health care organizations face mounting compliance concerns related not only new COVID-19 guidance and telehealth, but also the introduction of new Evaluation and Management (E&M) codes. Add an uptick in audit activity to the mix, and it stands to reason that revenue integrity must become a top priority.

Holistic approaches to revenue integrity ensure that all billing and compliance functions are working collaboratively to address all sides of a claim. They combine the power of prospective auditing to promote clean claim submission from the outset with retrospective auditing to speed process improvement initiatives. In addition, the best strategies rely on technology-enabled workflows and the power of automation, analytics and augmented intelligence (AI) to speed identification of risks, perform targeted audits, identify and address root causes, and monitor the impact of process improvement tactics.

As the industry turns the corner into 2021, these strategies will become paramount. Here are five trends that are shaping rapid adoption of holistic revenue integrity strategies:

1. Increased Oversight

Regulators had already intensified and enlarged their auditing roadmap before COVID-19 entered the US In late 2019, HHS’s Office of the Inspector General (OIG) recommended that the Centers for Medicare and Medicaid Services recover $54.4 million in improper payments to acute care hospitals due to incorrectly coded claims.

In addition, the health care industry now has months of COVID-19 incentive payments under its belt, and today’s C-Suite can expect a continuation of this trajectory in terms of increased scrutiny. Not surprisingly, the OIG recently announced its audit plans related to COVID-19 discharges. Within this trend, providers need to pay special attention to three categories of scrutiny: telemedicine, bundling and coding denials.

Rounding out oversight and compliance concerns is the recent introduction of new E&M codes as part of a greater effort to reduce provider administrative burden. While a positive step forward, documentation—and compliance—readiness hinges on a clear understanding of how documentation must now prioritize a holistic view of patient care.

2. Strong Emphasis on Revenue Capture

A perfect storm of financial issues introduced by COVID-19 has providers operating within tight margins and no cushion. Findings from a Physician’s Foundation report released in August 2020 suggest that US health care spending dropped by 18% during the first quarter of 2020, the steepest decline since 1959. From loss of revenue associated with elective procedures and outpatient visits to supply chain impacts, providers are facing a grim start to 2021 and must deploy strategies that ensure accurate and complete capture of all revenue opportunities.

3. Rapid Growth of Telemedicine

While the telemedicine revolution that caught fire in 2020 is driving greater access to health care, it is also creating nightmares for revenue integrity teams on the compliance front. The reality is that these new remote models of care are here to stay. For many providers, telehealth is unchartered territory that poses notable risks for reimbursement. Consequently, forward-thinking providers are increasingly implementing systems and processes that ensure complete, accurate capture of documentation necessary to support coding and billing activities.

4. Leveraging AI to Drive Holistic Revenue Integrity Practices

In tandem with the need for smarter approaches to revenue integrity are technological advancements that are making it easier than ever to implement sustainable strategies. Evolving revenue integrity models rely on better collaboration between all members of the revenue integrity team (finance, billing and compliance), and AI and analytics helps make this happen in a seamless way.  In addition, data-driven approaches to both prospective and retrospective auditing are elevating revenue integrity strategies. Resource-strapped provider organizations can now deploy emerging technology-enabled processes that support both a proactive approach to clean claims submittal and back-end review that enables rapid identification of process improvement opportunities.

5. Moving Toward Continuous Risk Monitoring and Prescriptive Analytics

AI techniques such as natural language processing and time series forecasting are further elevating revenue integrity strategies and enabling providers to move closer to real-time monitoring and prescriptive process improvement. Health care organizations will continue to embrace solutions that can track case mix index, elective surgery trends and average lag days from denial resubmission to adjudication on this level and allow revenue integrity teams to more rapidly detect data anomalies and outliers that can impact financial performance. Because AI systems learn from trends over time, providers adopting these tools benefit from more automatic application of needed changes to future claims.  

As the industry turns the corner into 2021, the financial challenges for today’s providers may not be over, but there is an opportunity for organizations to capitalize on progressive revenue integrity strategies. The best models draw on the power of advanced technology to holistically address revenue cycle and optimize financial performance.

Vasilios Nassiopoulos is Vice President of Product Strategy and Innovation at Hayes. A senior executive with over 25 years of healthcare experience, he possesses extensive knowledge of EHR systems and PMS software from Epic, Cerner, GE Centricity and Meditech.