How hospitals can recover millions through a revenue integrity plan

In today's stringent reimbursement environment, it's important for hospitals and health systems to take the steps necessary to maximize collections and optimize revenue cycle performance. Revenue integrity programs can help hospital CFOs do just that.

The National Association of Healthcare Revenue Integrity defines revenue integrity as the ability "to prevent the recurrence of issues that cause revenue leakage and/or compliance risks." Hospitals have seen great success when implementing revenue integrity programs. A Healthcare Financial Management Association survey of 125 hospitals and health systems found that with a revenue integrity program, 68 percent of hospitals saw an increase in net collections, 61 percent reported an increase in gross revenue and 61 percent had a reduction in compliance risk.

During a March 26 webinar presented by Becker's Hospital Review and sponsored by eSolutions, Chris Hart, vice president of product and strategy at eSolutions, discussed how hospitals can recover and collect millions through a revenue integrity program.

"When done correctly, a revenue integrity program can increase a hospital's revenues and decrease their uncompensated care and by extension, a hospital's bad debt, " Mr. Hart said. "Revenue integrity to us is all about finding missed reimbursement opportunities and helping healthcare providers capture it."

Components of revenue integrity program

There are multiple opportunities for hospitals to collect on uncompensated care. In 2017, hospitals provided $38.4 billion in uncompensated care, according to the American Hospital Association. Rather than send patient bills to collection agencies, hospitals can leverage artificial intelligence and other technology tools that sift through claims and accounts for missed payment opportunities.

Insurance discovery should be the foundation of any revenue integrity program. When eSolutions served as the primary reviewer for a 421-bed hospital, they reviewed 46,000 self-pay accounts. Through insurance discovery, eSolutions found that 5,000 of these accounts had billable insurance that had previously gone undetected. In total, the hospital was able to recover $2.9 million.

Revenue integrity plans can also address Medicare underpayments. These underpayments can be recovered through a charge capture, diagnosis-related group validation, and repricing and outlier payments.

Hospitals can also recover significant funds by focusing on transfer diagnosis-related groups (DRGs), as certain transfer DRGs are eligible for additional reimbursement. If a patient qualifies as a DRG patient, the hospital discharges to a post-acute care facility. However, patients don't always go.

Since transfer DRG payments cover all charges associated with an inpatient stay from the time of admission to discharge, it is up to the provider to identify and correct the claims. On average, hospitals can review up to four years' worth of Medicare claims on a retrospective basis. By reviewing these transfer DRG claims, hospital on average can collect an additional $3,500 per claim, according to Mr. Hart.

Reviewing these claims puts an added burden on the hospital's revenue cycle staff. When internal revenue cycle teams are overburdened, collections can ultimately suffer.

When eSolutions served as the primary reviewer for transfer DRGs at a 99-bed hospital in Northern Illinois, the organization was able to analyze 3.5 years of data. After reviewing 100 percent of those Medicare claims, the hospital was able to recover $100,000.

Looking ahead

When implementing a revenue integrity plan, hospitals should remember to file claims in a timely manner and use multiple vendors. There are potentially millions of dollars available to recover, but hospitals must work swiftly before the recoveries expire.

To learn more about eSolutions, click here.

To view the webinar, click here.

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