The Importance of Clinical Expertise in A Revenue Integrity Partner

Aug 5, 2021

When considering engaging a revenue integrity partner, it’s essential to focus on three main components: clinical expertise, the right technology, and proven client success.

Clinical expertise is critical in solving clinical and coding review challenges. Look for these important qualifications when evaluating potential partners:

  • A team of industry veteran nurses with multiple years of experience in both health plan and provider settings
  • Credentialed coders to conduct reviews
  • Various healthcare designations, including LPN, RN, MSN, CRNAC, etc.
  • Experience with various EMR platforms, such as Cerner and Epic
  • Deep expertise in clinical operations and billing workflows
  • Fluency in data analytics to proactively address growth challenges

An experienced clinical team can determine the viability of every claim your organization places, craft quality appeals, and ensure proper follow-up for appropriate revenue recovery. Data is vital to claim management; however, without proper analysis, data alone fails to address underlying causes and solutions. An experienced team can ingest the data, discover the root causes for clinical denials, and recommend and implement best practices related to the root cause and possible process improvements.

If an organization aims to achieve a more efficient time-to-revenue ratio, an experienced team focused on steadily improving KPIs and a shorter time to reimbursement is critical. A properly trained team will also report on progress toward KPIs.

While denial management experience is valuable when selecting a revenue integrity partner, that experience must include both payer and provider perspectives. Overturning appeals and managing backlogs becomes more difficult without understanding the full scope of medical necessity due to the many factors that go into overturning appeals and properly handling denied claims.

Well-trained and highly experienced revenue integrity staff—and a good support system for them—is critical to the success of any hospital and health system. Beyond providing immediate impact by bridging current gaps, a clinically experienced team can be impactful longer term by providing the information and best practices to solve core business issues. Appropriate and timely reimbursement will follow clinical experience, both independently and when combined with technology and proven client success.

TREND Health Partners provides solutions to the challenges that providers face in today’s healthcare environment. To discover the value that TREND can provide to your organization, connect with our team today.