Getting into the Revenue Cycle Groove: Part 1

Pursuing revenue cycle roles could be an ideal path for HIM professionals.

Often, we see patient financial services staff progress to leadership positions in the revenue cycle. When I have the opportunity to serve in such positions, I always wonder why we don’t see more health information professionals in these roles. The broad expertise of health information professionals is so perfect for it. 

Let’s start out by quickly defining revenue cycle. The revenue cycle is the compilation of activities, from pre-admission to post-discharge, that contribute to collecting reimbursement to which we are entitled. The process is cyclical for each encounter, and requires us to have a good understanding of the front, middle, and back-end activities of the cycle. 

Health information management (HIM) professionals already have a good handle on the mid-cycle activities, which often include a) case management’s role in ensuring that the admission and length of stay (LOS) have been authorized by the payor; b) clinical documentation improvement’s (CDI’s) role in achieving complete and specific documentation from our providers; c) timely capture of charges from the various charging departments, such as surgery, pharmacy, laboratory, ED, etc.; and d) the coding professionals’ role in assigning the most accurate codes to qualify for the correct diagnosis-related group (DRG). But revenue cycle activities entail more than just these tasks, and go beyond the inpatient arena. 

Understanding how each activity impacts other activities in the cycle is crucial for outpatient, professional fee, and inpatient services. The ideal revenue cycle executive must have processes in place to effectively manage payor contracts, fine-tune the chargemaster, build the claim scrubber, establish claim edits and protocols to collect accurate patient and payor information at the time of registering patients, validate eligibility, forecast costs for patients, identify causes that result in claims being rejected or denied, and perform a myriad of other tasks. 

Knowing the propensity for HIM professionals to dig into the details and establish practices to comply with the many billing and coding regulations, HIMers may find that pursuing revenue cycle roles is an ideal path for them. This leads me into why many organizations are changing the title of this domain to revenue integrity. Revenue integrity is all about ensuring that the appropriate safeguards and procedures are in place to accurately charge for services that are fully supported by the clinical documentation, are consistent with appropriate clinical practice, and are accurately reflected on the claim at the rate or rates to which we’re entitled. Partnering with compliance and having a robust revenue integrity committee structure is vital. 

For HIM professionals considering an opportunity as a revenue cycle executive but holding the belief that they need a more in-depth understanding of the front- and back-end activities, there are courses available from the Healthcare Financial Management Association. Over the next few months, we’ll explore issues confronting those managing this vital function.     

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