Slowing the Revolving Claims Door with Pre-Bill Revenue Integrity Reviews

For the majority of healthcare organizations across the country, the transition to ICD-10 was smooth – cases are being timely coded and dropped and revenue cycle A/R goals are being met. Don’t get too comfortable. Every leader in the revenue cycle should be asking the following questions:

  1. How have our denial rates changed?
  2. How has our denial mix changed?
  3. Are we maximizing revenue?
  4. Are we ensuring coding and documentation compliance?

Typically these questions are answered by different departments across the organization, each of which have their own mitigation strategies. Because of the silo environment in hospitals, much, if any, of the claims analysis occurs on the back-end requiring additional time and resources, both of which are scarce in the current environment of increased regulatory oversight, audits and reimbursement methodology changes.  It is now more important than ever before to proactively assess compliance and revenue capture.Use pre-bill revenue integrity reviews to increase the quality of healthcare claims

Much like the increased emphasis on quality in healthcare, the new mantra should be getting quality claims out the door and not simply quantity. What method can help address the questions above and produce quality claims on the front end? Pre-Bill Revenue Integrity Reviews.

How Do They Work? Working with leaders in revenue cycle, HIM and clinical documentation improvement, we identify specific cases (e.g., high volume/revenue, high denial rate) to be held each day before submitting for billing using flags within the electronic medical record. A second level review is conducted within 24 hours to ensure compliance with coding and documentation guidelines including DRG assignment.

What is the Benefit?  Quality claims going out the door – reduces denials, limits potential repayment, maximizes revenue and confirms compliance.  Healthcare organizations will spend less time working denials and defending appeals and will recognize revenue that would otherwise be left on the table.  Our experience has the following proven results:

  • DRG shifts: 15%
  • Benefit per chart reviewed: $1000+
  • Value per chart with recommended change: $5,000-10,000
  • ROI: $7-$15 rebill opportunity per $1 of Audit Cost

Proven results with Provident


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