MDaudit Examines the Latest Trends, Issues, and Solutions to Revenue Integrity Strategy
For payers and health systems, revenue integrity strategy drivers for 2022 and beyond come down to higher patient volume and heightened regulatory scrutiny. That’s based on a review of data encompassing more than $100 billion in denied claims from a large cohort of users within the MDaudit ecosystem – an ecosystem that provides unique insights into evolving trends that can help shape revenue integrity strategies to streamline claims processing and reduce denials.
A Closer Look at Revenue Integrity Trends and Challenges
The first trend affecting revenue integrity is probably the most obvious; this year, there is higher patient volume than we saw in 2021. This means that alongside staffing shortages and a tightened auditing and financial review landscape, health systems face negative revenue impacts requiring careful allocation of resources, tools, and technologies to contain and manage costs associated with services provided.
Second, on the regulatory front, numerous critical updates are coming from CMS and OIG. One particularly notable call-out is the HHS budget – about $2 billion allocated for Medicare and Medicaid program integrity. This means we can expect an uptick in external audits of claims paid, with COVID-related services receiving the most scrutiny. Managing these and ensuring revenue integrity remains of vital importance.
Finally, commercial payers are increasingly using technology (AI/ML) to rapidly analyze large volumes of claims before adjudicating them, resulting in more rejections. This is something that the providers need to start proactively managing to ensure once the claim goes out the door, it doesn’t get kicked back.
Needless to say, AI/ML will play a significant role in both the provider and payer spaces. When we looked at our ecosystem of denials in 2021, we saw around 3 out of 10 claims denied, a trend we expect to escalate throughout the year.
For example, when looking at denial data in the last 12 months and the percentage change in average denial per claim, the average dollar per claim in the practice setting increased by 3%. On the hospital outpatient side, it increased by 4%. Claims volumes are higher, but so are what is being denied and the value of each rejection.
When we looked at what was happening on the practice side, we saw many claims submissions, billing errors, and missing documentation which resulted in denials. Many claims were also denied for telehealth services for similar reasons. On the hospital side, most denials were related to bundling and COVID-19-related services.
Common Ground for Revenue Integrity Strategies
When it comes to revenue integrity strategies, it is not a one-size-fits-all proposition. But there is a common thread, which can be summed up as cross-department collaboration and shared strategic goals. When queried about what their organization wanted to achieve in terms of revenue integrity and what they would consider success, two things emerged: The need to ensure that revenue opportunities are maximized and to achieve operational efficiency.
The latter is where analytics and technology play a significant role. Unfortunately, in most organizations, information gets lost, or there are disconnects between departments and processes. This hampers revenue integrity programs, which must be cross-functional and involve multiple departments, including billing, compliance, revenue cycle, coding, clinical, and IT. These programs require a platform to make these cross-functional processes happen by allowing everyone to see the same data and easily share insights.
Here’s an example of this idea in practice: A health system with more than 40 facilities conducted risk-based audits during COVID-19 and discovered that a set of providers were improperly billing a particular service. When this was brought to the group’s attention, the providers indicated that the issue was a technology – not personnel – problem. So, the disconnect between the two parts found its solutions because of a comprehensive data review and the coming together of leaders across several areas.
A Four-Step Process for Revenue Optimization
Using analytic tools to catch issues proactively, like the health system in the example above, helps identify where risks reside and to channel these insights into targeted prospective processes. It is a four-step analytics process encompassing:
- Risk analysis, a diagnostic process to understand the root causes of the risks.
- Risk mitigation via audits, either scheduled or as part of risk remediation efforts, to determine necessary actions based on risk profiles and targets.
- Educating providers, third-party vendors, coders, and even third-party auditors on revenue integrity processes.
- Ongoing risk monitoring.
The large volumes of data needed for monitoring and analytics can be automatically generated through AI and machine learning. At MDaudit, we ensure that those data are continuously ingested into our platform to identify risks across facilities and systems.
These are just some advantages of utilizing a modern cloud-based revenue integrity platform like MDaudit. Once revenue optimization has been determined, denial risk can be evaluated. This leads to seamlessly running pre-built charges through a predictive engine, which can tag potential denials for remediation — retrospectively and prospectively.
To kick off the process and get your departments on the same page, schedule a demo with us to learn how.
