Going Fishing: A Look at Revenue Integrity

KLAS has had conversations with providers and vendors over the course of several months, and the second we figured that we had a good definition for revenue cycle integrity, we would talk to another person that would throw off that definition. The definition of revenue cycle integrity really depends on who you talk to across different health systems. I have heard everything from the narrowest definition, where it is only people that help with charge integrity, to the broadest, where people say that revenue cycle integrity is any firm that helps healthcare organizations get paid for the work they've done. The field is spread out and broad, but there is still a lot in between.

We struggled for months to define this and figure out how KLAS could measure this space. Finally, we determined that we should let health systems define revenue cycle integrity however they want. However, we at KLAS need to be able to check the boxes and verify which vendors do what at this point. One of the big differentiators in the Revenue Integrity/Underpayment 2019 report is what the vendors do and not so much how well they do it.

Fishing For You

We created a fishing analogy to clarify exactly what kinds of services are being offered. There are three different kinds of firms: firms that will fish for you, like BESLER, Triage Consulting Group, and Revecore; firms that will provide you with the tools to fish, such as TransUnion Healthcare; and consulting firms that will come in and teach you how to fish, like PwC, Deloitte, Accenture, Navigant, and Huron.

This report really focuses on the firms that will fish for you. That basic interaction looks something like this: the billing office of a health system has a patient with private insurance come in for hip surgery. After the surgery, a claim is submitted to get paid. By contract, that insurance company was supposed to pay $5,000, but they only paid $4,000. Maybe that goes unnoticed, and because the bill got paid, it gets zeroed out and everyone moves on. A revenue integrity firm comes in, audits everything, and finds that the insurance company underpaid your organization by $5 million this year. The firm then does all the paperwork and works with the insurance company, and your organization then pays the firm whatever their going rate is. So, if they found $5 million dollars, maybe you pay them $1 million for it.

Fishing Partners

Overall, each of the firms in the report are incredibly high performing. The reason these firms perform so highly is because the metrics are aligned. The vendor doesn't do well unless the provider does, and vice versa.

Revenue cycle integrity firms are only getting paid on contingency, meaning that they only get paid on what they can find. Despite that, one of the cool things that we've seen vendors do in the space is to look upstream and point out areas where an organization can improve. It may seem like this shoots the firm in the foot a little bit for future findings, but by doing so, they build a good partnership that leads to the high KLAS scores you'll see. If a vendor is not performing here, they tend not to stay in the space; they get pushed out. The service is so dependent on contingency that an organization can bring in another firm to work in front of the other and pick up the low hanging fruit before the original firm gets a chance to do it.

Possibilities in the Future

Looking at the report, Revint has the broadest offering in terms of services. It will be interesting to see whether that trend catches on with other vendors. We can talk to one health system that is using Revint today that tells us that they tend to use only one service. Then we'll talk to another organization and they tell us that they're using an entirely different piece. Maybe this is because these organizations are on some of the legacy products that Revint brought together and that these organizations have always worked with that piece, but maybe not. 

KLAS is aware that there are still more vendors to measure in this market. Our fishing analogy works only so far because a lot of firms are kind of mixed in what they do. We have vendors tell us that they do consulting, but that they also help their organizations do revenue integrity themselves. So, we will get deeper into more of the tools as time goes on. KLAS is also hearing that a lot of providers have more of an interest in the tools and technology because healthcare organizations would much rather paint their own house than pay someone to do it. It's hard to deny that that method can be cheaper.

To see more use-case validations and to see which firm’s offerings would work best with your organization, I recommend reading the full report.




     Photo cred: Adobe Stock, smiltena