Using Technology to Decode Revenue Integrity Through the Lens of Providers is Key to Accelerating RCM Transformation

Nitin Dua
Wed 24 Aug 2022
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In the context of healthcare, revenue integrity essentially comes down to making sure that each clinical encounter is accurately translated into revenue. In order to achieve this, people, processes, and platforms—all play an important role in realizing operational efficiency, compliance, and optimal reimbursement. In other words, revenue integrity ensures that all patient services are correctly captured, billed, and paid for while ensuring regulatory compliance and an optimal patient experience.

Around 75% of revenue in U.S. healthcare comes from the fee-for-service payment model. However, margins are low in this model, around 4-8%. The total spend on administrative tasks increased 12% YoY, while the total spend as per CAQH exceeded $37B for 2021 on administrative RCM functions. Interestingly, over the same period, volumes decreased by nearly 11%, suggesting the cost to process was high. The trend continues to pinch health systems and their RCM budgets.

Moreover, amid the transition from fee-for-service to value-based care and payment models, claims management continues to be a weak spot in revenue cycle management, affecting the bottom line. As a result, health systems adapting to the new risk-adjusted financial models that drive value-based care and population health are moving toward revenue integrity strategies that resonate with the adage ‘prevention is better than cure,’ thus focusing on claims management at its initial stage to minimize the risk of denials and improve the prospects of recovery.

Bringing Billing, Operations, and Compliance Together

To achieve revenue integrity, it is important for providers to apply technology solutions that drive revenue cycle optimization. This, in particular, will help target billing, operations, and compliance to get these disparate systems working together and create a seamless experience for patients while maximizing financial margins.

While providers today target numerous goals with revenue integrity, including better revenue capture, reduction in accounts receivable days, documentation improvements, charge process efficiency, and workflow optimization, the core mission remains clinical and operational workflow congruency. With the right technology supporting this model, providers can reduce claim denials and cost to collect, while significantly improving clean claim and recovery rates. This is where Innovaccer’s Denial Prevention and Recovery Accelerator steps in to help providers achieve revenue integrity.

Pressure Grows to Enhance Revenue Integrity

The burden on health systems continues to grow, indicating why revenue cycle transformation is imperative for providers today. These facts are telling!

  • ~90% of claim denials can be prevented with front-end, mid-cycle, and back-end improvements
  • $8.6 billion is spent by hospitals appealing claims as additional administrative costs
  • 79% of RCM areas use outdated technologies as stand-alone applications, which are not integrated into other RCM processes and therefore drive inefficiencies
  • $25.00 is the average cost to rework a claim

Interestingly, despite being preventable in most cases, denials continue to contribute a sizable portion of revenue leakage. According to a recent report by the Healthcare Financial Management Association (HFMA), out of $3 trillion in total claims submitted by healthcare organizations, $262 billion were denied, translating to nearly $5 million in denials on average per provider.

Providers are looking for claims management solutions that not only improve their revenue recovery prospects but also enhance clinical outcomes. In this regard, Innovaccer’s Denial Prevention and Recovery Accelerator is an innovative choice as an RCM solution for health systems concerned or struggling with regulatory compliance, and finding it hard to plug revenue leaks amid rising claim denial rates.

Transform the Revenue Cycle With the Denial Prevention and Recovery Accelerator

Working seamlessly across the revenue cycle, the Denial Prevention and Recovery Accelerator, as part of Innovaccer’s Revenue AI suite, reviews each and every charge for coding completeness and accuracy before a claim is created. The solution is Innovaccer’s answer to data fragmentation causing a lack of visibility across the claims cycle leading to poor analytics and decision making. By unifying and cleaning data at the beginning of the process, it helps providers save hours of manual work while ensuring encounters accurately translate into revenue. This helps organizations hit their financial targets through reliable, predictable revenue generation.

Using the power of the Innovaccer Health Cloud, the Denial Prevention and Recovery Accelerator facilitates data activation and analytics to simplify claims management, reduce preventable denials, and accelerate payments while allowing providers to improve their financial strength to support exceptional care delivery.

To learn how we can help you transform your revenue cycle with data activation and advanced analytics, get a demo or talk to one of our experts today.


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Tags: RCM
Nitin Dua
Product Marketing

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