Revenue Integrity in 2024: Reducing Leakage Points in a Complicated Cycle

Revenue Integrity in 2024: Reducing Leakage Points in a Complicated Cycle

The concept of “revenue integrity” hasn’t really changed over the years, but the roles, responsibilities, and oversight have become far more complex and difficult to gain industry consensus around. What began as several defined systems of controls by which hospitals guarded against revenue loss, revenue integrity has seemingly turned into more narrowly focused controls in many organizations, leaving critical gaps in what once was a more holistic approach to fiscal oversight.In short, revenue integrity simply means ensuring providers are paid appropriately for all services provided and in an efficient and compliant manner to prevent revenue leakage and compliance risk. That’s easier said than done.An increasingly complicated payer-provider landscape and rising staff shortages are magnifying the disconnects between clinical and administrative metrics, technologies, and processes. These challenges are further compounded by technology and digital transformations, system consolidations, and organizational restructuring across many hospitals and health systems – exposing more possibilities for revenue loss than ever before.

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One of the largest drivers of revenue leakage and financial strain outlined earlier stems from denied reimbursement from insurance claims. Creating sound processes throughout the revenue cycle and leveraging objective data to ensure all stakeholders are aware of the opportunities, risk, and financial impact, improves collaboration and reduces gaps. When 35% of hospitals report losses greater than $50 million due to exhausted insurance appeals, the need to address revenue integrity externally must be mentioned as well.One approach hospitals can take is creating open lines of communication with their payers, and leveraging objective data to solve for subjectivity in complex and inconsistent payer policies.  Much like the collaboration objective data can create internally, an intentional and objective approach can create better alignment with your payers.

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