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Your Healthcare Revenue Integrity Annual Check-up: 5 Things to Watch

The old adage of “prevention is better than the cure” rings true for a proactive healthcare integrity mitigation strategy, but the work is not for the faint of heart. It takes perseverance, expertise, patience, and a well-thought-out plan.

Marcy Utley, Senior Product Manager at SAI Global, explains five steps to help you build a sustainable mitigation strategy. 

Demonstrating effective monitoring and auditing is a crucial element for all compliance programs. But this can often be the most daunting and intensive task. Many resources and time can be put into planning for something that may never happen, but logic dictates that by pre-emptively seeking out issues, you’re effectively extinguishing the flames before the fire has started.

By implementing a well-laid-out plan for revenue integrity, healthcare organizations can not only effectively demonstrate adherence to rules and requirements but also correctly identify drivers of risks to grasp the key issue along with assessing the likelihood and impact in order to prioritize risks, which makes creating a contingency plan a lot easier.

Let’s examine the steps involved to help enable you to create a proactive mitigation strategy:

1. Review awareness of regulations and external risk areas

A proactive risk strategy generally consists of focusing efforts on mitigating the risk of pre-emptive threat occurrences. This involves devising plans to protect critical assets via educating the business about the who, what, where, why and how threats can potentially expose their valuable, sensitive assets. But where do you start?

First, you need to become familiar with the legislative universe of your organizations. After all, the impact and probability of risks that legislation represents depend on the attention paid to the legislation and how well risk and regulatory compliance management is entrenched within your organization.

Information releases happen from a combination of sources such as Office of Inspector General (OIG) reports, posted Targeted Probe, and Educate (TPE), and Recovery Audit Contractor (RAC) audit issues. Additionally, reviewing the Comparative Billing Report (CBR) for your possible audit areas for healthcare providers and provider compliance quarterly reports can be extremely valuable resources.

Having a software solution will allow you to distribute and assess this information as well as regulatory information efficiently can be critical to your organization’s success in managing revenue integrity.

2. Look inwards – observe and identify

Once you have reviewed the external information releases, it’s time to focus on your own organization and start to identify internal risk factors.

It’s worth asking yourself:

  • What do you know about your organization as it relates to the payer and administrative oversight areas of focus?
  • Do you have robust controls in these areas? Review your staffing and educational efforts and subject matter expertise
  • When was your last chargemaster review, and do you have results from past audits that point to your organization’s understanding of particular service areas? Also, a focus area should be for things that have changed or are challenging to get right
  • Have you begun to offer a new service or service line?
  • Are there changes in the billing codes for a service or changes in how a payer reimburses a service?
  • Do some services require documentation requirements that are difficult to adhere to and demonstrate?

But beware, information overload can happen quickly if you are attempting to manually gather this information by monitoring list serves or reviewing websites for updates. You are most likely to miss essential data if you are trying to rely on spreadsheets to capture all of the numerous and critical elements of each healthcare claim audit and denial you are receiving.

3. Get to know and understand your data

With the enormous amount of information in front of you to review, an analysis of your revenue data will be essential in refining your focus list.

Some questions to ask are:

  • Who are your highest ordering providers?
  • How are your various payers reimbursing services?
  • What are your volumes of services provided in terms of dollars and counts?
  • What healthcare services have the highest margins?

To help identify where to focus your auditing and monitoring resources, it can be beneficial to pay close attention to trends around the volume of patient care services provided, charges and payments as they increase or decrease over time. For example, if you see a service line such as oncology decreasing over time, it may be best to focus on other service areas.

Benchmarking is a critical tool for understanding the areas that your organization is an outlier in revenue integrity (or leakage). This will help to identify areas of importance. Being an outlier does not necessarily mean you are doing anything inappropriately. Still, you do need to perform a review of the service area in question and validate that their aberrancy is appropriate. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) has been a vital tool for identifying outliers for many years. The extension of PEPPER from acute hospitals into a total of nine areas adds valuable insight for comparing your healthcare organization in risk areas that are of interest to revenue integrity programs.

Along with managing PEPPER data, attention should be paid to Comparative Billing Reports (CBR). These reports provide results of statistical analysis that compare an individual provider’s billing practices for a specific billing code or policy group with the billing practices of that provider’s peer groups and national averages. Sample letters and webinars are available as each new CBR audit is conducted.

4. “To audit . . . or not to audit”? (Well that’s a good question)

How formal will your review of revenue information be? Many times, to determine the answer to this question, it may be best to start with an assessment. Knowing what policies and controls are in place for your area of focus are essential but not nearly as critical as in what way stakeholders in your organization interpret and comprehend the policies and apply the controls. During the assessment, if you identify a gap between requirements and application of policies and controls, you may be better served to conduct education sessions to quickly change behavior rather than immediately jump into a time-consuming audit.

Once an audit begins, be sure to define the scope clearly. Make a point to include leadership so they aren’t left in the dark and surprised by your findings, particularly those in the area that the audit will be focusing on.

Are you auditing a distinct area of a patient procedure, or are you performing a birth-to-death audit?

Both have their place in different situations. Scope creep can happen if you aren’t disciplined.   The need for expansion of the audit should be done as a result of a disciplined audit with a defined scope.

5. Review and refine for continuous improvement

Once the results are established, appropriate corrective action or education plans are put into place. Socializing the outcomes and next steps is critical. Ensure that proper leaders have had a chance to review the audit report and provide comments. If leaders have an opportunity to review the scope, they will then expect results and can help champion the next steps in your revenue audit process.

Commitment through the completion of the corrective action and education process is a place that many healthcare organizations fall short, or the audit cycle loses steam. So much work and effort go into the audit that if the audit is worth beginning, then it is worth completing it appropriately and wholly. Completion of all action plans is key to demonstrating you have an effective process. Once the audit has concluded, it is time to monitor and reassess. The process is cyclical, and you are never finished — just discovering, reviewing, and refining.

The application of a proactive risk approach to healthcare revenue integrity is so beneficial, it’s hard to see why people and businesses alike would neglect to employ any other strategy. The ability to see risks and opportunities simultaneously helps to develop a flexible organization that can manage value protection and creation asynchronously.

Developing the ability and resources to recognize these opportunities is crucial in aiding a healthcare organization to better manage and benefit from inevitable risks, drive competitive advantage, and sustain future profitability and growth.


In her blog series on Managing Revenue Risk, Marcy discusses ways to conduct proactive mitigation to avoid potential non-compliance. Missed a post?

Part one: Our 360-degree approach to reducing denied claims

Part two: How automated workflows differ from work queues in supporting collaboration on payer audits and denial appeals.

Let’s discuss how SAI Global’s Revenue Risk Manager can help your revenue integrity mitigation strategy.

Learn more about our Revenue Risk Manager.