Core Functions of Revenue Integrity

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Core Functions of Revenue Integrity

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Available December 2017

Core Functions of Revenue Integrity

Valerie A. Rinkle, MPA, ACHE | Sarah Goodman, MBA, CHCAF, COC, CCP, FCS | Terri Rinker, MT (ASCP), MHA  | Anna Santoro, MBA, CCS, CCS-P, RCC | Donna Schneider, RN, MBA, CPHQ, CPC-P, CHC, CPCO, CHPC | Angela Simmons, CPA

Available December 2017

As more facilities develop revenue integrity programs and departments, there is an ever greater need to develop educational materials and training for these professionals. NAHRI's Core Functions of Revenue Integrity examines how each piece of revenue integrity comes together on a macro and a micro level by looking through the lens of 10 core functions. It provides actionable advice and guidance for revenue integrity professionals, whether they are new hires or experienced veterans.

This book provides a well-rounded perspective on revenue integrity, covering everything from payment systems and reimbursement methodologies to denial appeals and charge capture review. It is authored by six NAHRI advisory board members whose collective knowledge and experience will help revenue integrity professionals ensure their programs are running effectively and capturing revenue opportunities. 

Benefits of this guide include:

  • A broad perspective of revenue integrity across 10 core functions, ranging from introductory to advanced topics
  • Trusted guidance by expert contributors from across the country
  • The ins and outs of revenue integrity in one comprehensive resource 


About the authors:

Valerie A. Rinkle, MPA, ACHE, is a lead regulatory specialist and instructor for HCPro's Revenue Integrity and Chargemaster Boot Camp®, as well as an instructor for HCPro’s Medicare Boot Camp®—Hospital Version and Medicare Boot Camp®—Utilization Review Version. Rinkle is a former hospital revenue cycle director and has over 30 years in the healthcare industry, including over 12 years of consulting experience in which she has spoken and advised on effective operational solutions for compliance with Medicare coverage, payment, and coding regulations. Rinkle serves as an advisory board member for NAHRI.

Sarah Goodman, MBA, CHCAF, COC, CCP, FCS, is president/CEO and principal consultant for SLG, Inc., in Raleigh, North Carolina. She is a nationally known speaker and author on the charge description master, outpatient facility coding, and billing compliance, and has more than 30 years’ experience in the healthcare industry. Goodman has been actively involved and held leadership roles in a number of professional organizations on the local, state, and national levels, including the NAHRI.

Anna Santoro, MBA, CCS, CCS-P, RCC, is revenue integrity director at Hartford Healthcare in Newington, Connecticut. She has 20 years of experience with chargemaster, claim edits, denials, and coding. Santoro serves as an advisory board member for NAHRI.

Donna Schneider, RN, MBA, CPHQ, CPC-P, CHC, CPCO, CHPC, is system revenue compliance officer at Yale New Haven Health in Connecticut. Schneider is a registered nurse with a bachelor of science degree in nursing and an MBA, both from the University of Connecticut. She has over 30 years of healthcare experience in clinical intensive care, managed care contracting, network management, quality, compliance, privacy, and quality analytics. She serves as an advisory board member for NAHRI.

Angela Simmons, CPA, is vice president of revenue and reimbursement at Vanderbilt University Medical Center in Nashville. A Texas Certified Public Accountant, she brings more than 30 years of experience in healthcare operations and finance, and public accounting for healthcare entities. Simmons has expertise in healthcare policy, reimbursement principles from government programs (Medicare and Medicaid), as well as healthcare financial analysis and cost accounting. Simmons serves as an advisory board member for NAHRI.

Terri Rinker, MT (ASCP), MHA, is revenue cycle director at Community Hospital Anderson, an affiliate of the Community Health Network in central Indiana. She thrives on working with her team to develop new and improved processes for the revenue cycle, and was awarded her organization’s award for innovation in 2012. She serves as an advisory board member for NAHRI.


Page count: 150
Dimensions: 8.5” X 11”
ISBN: 978-1-68308-658-1

 

Table of Contents

  • Introduction 
    • Overview of the Core Functions of Revenue Integrity
  • Understanding the Revenue Cycle 
    • The Connection Between Revenue Cycle and Revenue Integrity
    • The Role of Revenue Integrity Staff 
  • Denial Management
    • Denial Trends
    • The Appeals Process 
  • Code Edit Management 
    • Outpatient Code Editor
    • National Correct Coding Initiative
    • Revenue Codes
  • Charge Capture 
    • Chargemaster Management
    • Clinical Education of Charges
    • Order Entry
    • Encounter Forms
    • Charge Triggers
  • Eligibility
    • Insurance
    • Coordination of Benefits
    • Patient Liability
    • Financial Counseling 
  • Coverage
    • Medical Necessity
    • Coverage Policy
    • Waivers and Notices 
  • Regulatory Changes
    • Conditions for Payment vs. Conditions for Coverage
    • Monitoring Regulatory Changes
    • Communication, Education, and Resources
  • Finance
    • Income Statements
    • Cost Reporting
    • General Ledger 
    • Contract Management
    • Third-Party Follow-Up and Payment Processing 
  • Payment Systems
    • IPPS/OPPS
    • Quality and Value-Based Programs
    • Ambulatory Surgical Centers
    • Medicare Physician Fee Schedule
    • Per Diem
    • Capitation
  • Coding Principles
    • CPT 
    • HCPCS
    • ICD-10
    • Modifiers