The #1 Problem Every Hospital Mentioned - And What We Learned at Three Major Revenue Cycle Conferences

We just returned from an intensive week at three major healthcare conferences: the Denials Management Exchange, Open at Epic, and the Revenue Integrity Symposium. At the DMEx our founders conducted an engaging workshop with several revenue cycle leaders focused on identifying and addressing critical bottlenecks in inpatient revenue cycle operations. In the video Adi Tantravahi and Juan Sebastian Lozano break down the most impactful discussions and solutions that emerged from this collaborative session.

Below, we've included a comprehensive summary of key sessions from the Revenue Integrity Symposium to give you the full picture of where the industry is heading.

Panel Session Highlights

Revenue Integrity Tools and Metrics to Drive Success

Mayo Clinic Team (Kelli Howard, Howard Kung, Brittany Morgan)

Mayo Clinic showcased their internally developed REI (Revenue Education and Initiatives) platform, demonstrating how structured revenue integrity programs can deliver measurable results. Their comprehensive approach focuses on four core functions: charge variance, charge lag, charge reconciliation, and write-offs, integrating these into a unified tracking and reporting system. The platform evolved over multiple years from an education-focused tool to a comprehensive one-stop shop for revenue integrity operations. Site-based analysts operate remotely with dedicated site assignments, developing specialty expertise while integrating with clinical practices through monthly finance meetings and real-time provider consultations. Their Tableau-based dashboards provide department-level and pending revenue analysis tied to the general ledger, with standardized monthly deliverables including charge variance analysis and charge lag tracking. The team emphasized starting small with measurable core functions before platform development, with partnership accountability essential across all organizational levels for sustainable success.

Beyond the Build: EHR Implementation and Revenue Integrity Evolution

Avera Health (Tim Schwasinger) and Eide Bailly (Rachel Pugliano)

Avera Health's revenue integrity department launched in early 2023 following an HIM coding assessment recommendation, initially including a director, two team members from the denials team, and a seven-person charge description master team. Their journey through EHR implementation revealed a critical lesson: because RI did not report to IT, the team was excluded from Epic training early in the process, resulting in missed opportunities during workgroup formation. The presenters emphasized that RI requires the same foundational EHR understanding as IT given their roles in CDM mapping and charge capture workflow design. During implementation, Avera's RI team played active roles in hospital billing, professional billing, integrated charging, contract management, facility structure, and professional coding workgroups. Their key recommendations: send RI to EHR training immediately and identify which workgroup handles clinical charging workflows to advocate for early involvement in decisions affecting revenue cycle processes.

Standing Up a Revenue Integrity Program: From Vision to Reality

Denver Health (Carrie Wise)

Denver Health's experience building a revenue integrity program from the ground up offers valuable lessons for organizations at any stage of development. Despite significant leadership turnover and organizational challenges, their team successfully established a comprehensive program integrating clinical documentation improvement, utilization management, and denials management under unified leadership. Wise's presentation highlighted that successful program implementation requires strong clinical backgrounds, organizational commitment, and the ability to demonstrate value through measurable outcomes like improved CMI and enhanced capture of comorbidities.

Managing Your CDM: Is it the Revenue Integrity Safety Net?

Kay Larsen (Adventist Health Glendale), Peggi Ann Amstutz (Panacea Healthcare), Sarah L. Goodman (SLG, Inc.)

The charge description master serves as a critical service instrument supporting both patients and clinical teams, requiring true collaboration across coding, finance, IT, revenue cycle, and clinical departments with physician champion engagement. The presenters emphasized substantial risks when adding new services without timely charge creation, leading to costly re-billing cycles and revenue leakage. CDM leaders should actively participate in new hire orientation, quarterly clinical department meetings, denial management sessions, and physician compensation committees. Key recommendations include adjusting fee schedules based on actual payer mix rather than simple Medicare multiples, incorporating CDM reviews into formal compliance plans and audit schedules, and using the NCCI Policy Manual alongside CPT guidelines to align coding with payer expectations. The fundamental message: proactive CDM management prevents denials before they reach accounts receivable.

Optimizing Hospital Pricing Strategies

Children's Hospital Colorado (Luis Aguilar and Gregg Fanselau)

Children's Hospital Colorado presented a sophisticated approach to hospital pricing that balances revenue maximization with patient affordability and market competitiveness. Their comprehensive pricing workfile incorporates multiple data points including RVUs, costs, competitor prices, and patient responsibility percentages to inform strategic decisions. The team emphasized the importance of the "5 Cs" in pricing strategy while demonstrating how data-driven approaches can help organizations navigate the complex landscape of price transparency requirements while maintaining defensible and sustainable pricing models.

NCCI Edits: Beyond Coding to Denials Management

HCPro (Amy Inch)

Understanding NCCI edits extends far beyond basic coding knowledge, directly impacting denials management and revenue recovery. The presentation detailed how NCCI edits integrated into the Outpatient Code Editor create immediate return-to-provider scenarios that cannot be appealed, making prevention essential. Organizations must invest in education and system edits to prevent these denials proactively, as retroactive fixes are often impossible, highlighting the critical importance of getting it right the first time.

Ensuring Appropriate Reimbursement and Preventing Denials: The Role of CDI in Office Visit and Ancillary Service Documentation

Deanne Wilk (HCPro)

Clinical Documentation Integrity has expanded beyond traditional inpatient focus to serve as a critical bridge between clinical care and coding in outpatient and ancillary settings. Deanne Wilk outlined how CDI's role in reducing denials and ensuring correct payment has become essential as payers increasingly scrutinize documentation. Common pitfalls include missing or vague diagnoses that trigger claim rejections, lack of linkage between documentation and orders, and insufficient medical necessity documentation. For ancillary services, CDI teams must collaborate with radiology, laboratory, physical therapy, and scheduling departments to ensure orders are complete before services are rendered, and build documentation standards directly into EHR templates and order sets. The key strategic shift: moving from reactive denial handling to proactive prevention through documentation excellence, recognizing that documentation is fundamentally a team sport requiring clinician and staff collaboration.

High and Low Tech Solutions for Provider Workflows

ECU Health (Dr. Vaughn Matacale)

ECU Health's innovative approach combines sophisticated technology with practical solutions to enhance provider engagement in documentation improvement. Their outcomes speak volumes: achieving approximately $3 million in CMI impact, improving capture of eight out of twelve key comorbidities, and maintaining over 88% query affirmation rates. The presentation emphasized that successful CDI programs require flexibility to accommodate busy clinician workflows while providing clear, actionable feedback through both automated systems and human interaction.

Who, What, Why & How! Cooper University Physician Advisor Program

Deepa Velayadikot, MD (Cooper University Hospital)

Cooper University Hospital has developed a comprehensive physician advisor program engaging 25+ hospitalist physicians who actively practice clinically while serving as advisors. The program expanded from Cooper's main campus to contracted services across multiple regional hospitals. The innovative "Clinical Care Physician Advisor" model ensures proper documentation and level-of-care decisions from the point of entry—emergency department, transfers, and elective admissions. The program requires two physician advisor concurrence before any downgrades or denials, ensuring clinical validity. Cooper has integrated academic training with a 4-week student clerkship through Cooper Medical School of Rowan University, teaching the next generation about patient advocacy and documentation importance. The program maintains rigor through monthly physician advisor conferences featuring case reviews and regulatory updates, annual CME requirements, and real-time audits by senior advisors. The comprehensive education strategy includes organization-wide medical staff training twice yearly, specialty-specific sessions for surgical residents, and new hire integration, all emphasizing that hospital financial benefit is a byproduct of proper patient and physician care.

A Clinical Approach to Combating Medical Necessity Denials

CalvertHealth Medical Center (Noelle Flaherty) and HCPro (Teri Rice)

Medical necessity denials require a sophisticated clinical approach that goes beyond traditional appeals processes. The presenters outlined strategies for identifying different types of medical necessity denials and emphasized the importance of addressing issues before discharge whenever possible. Their collaborative model brings together revenue cycle teams, utilization review, and clinical staff to create comprehensive denial prevention strategies that address root causes rather than simply managing symptoms.

Denials Tips and Tricks: Clean Claims Out the Door!

Nancy Blattberg-Smith and Michelle Knuckles (University of Utah Health)

University of Utah Health has achieved 16 consecutive years as a top-tier Vizient Quality & Accountability Scorecard performer through a sophisticated approach to clean claim submission. The organization's integrated Coding, CDI, Auditing & Education functional model breaks down traditional silos, with coders specializing by service line and working concurrently through discharge, CDI nurses conducting concurrent reviews and managing clinical validation processes, and Quality Liaisons bridging multiple departments. Utah Health employs third-party vendor reviews of coded data against thousands of coding and NTAP rules, with findings informing pre-bill review strategies to catch issues before claims submission. The organization maintains a library of proven appeal phrases and consults with physician advisors for complex cases. Utah Health has received formal recognition including vendor auditing awards and the EPIC Gold Trophy for DRG Denials Excellence, demonstrating that clean claims with correct DRGs, optimized reimbursement and risk adjustment, and enhanced cross-team communication create sustainable competitive advantage.

Innovations in Healthcare Reimbursement: What's Next?

Taylor Brown (Crisp Regional Hospital)

Healthcare reimbursement is evolving rapidly, with innovation shifting from optional to essential for organizational survival amid tighter margins and stricter compliance requirements. Taylor Brown outlined convergent pressures including prior authorization delays, increasing denials, growing price transparency enforcement, and the accelerating shift to value-based care. By 2027, CMS projects over 60% of Medicare payments will be value-based, fundamentally changing incentives from volume-driven to outcomes-driven care. Brown presented evidence that pre-bill review automation delivers measurable improvements in denial identification speed and workflow efficiency. Traditional revenue cycle management characterized by manual processes, reactive denial handling, and siloed departments must give way to innovative approaches featuring automated workflows and AI-driven tools, proactive denial prevention, cross-functional collaboration, and real-time analytics. Looking ahead, the evolution of Bundled Payments 2.0 with enhanced accountability and outcome measures will require hospitals to strengthen care coordination and leverage advanced analytics to monitor both cost and quality simultaneously.

Innovations in Healthcare Revenue Cycle

Panel Discussion on Technology and Automation

The symposium highlighted groundbreaking innovations transforming revenue cycle management, particularly through artificial intelligence and automation. Real-world case studies demonstrated 20% reductions in FTE requirements for claim status workflows, 33% decreases in manual touches, and denials identified up to 14 days faster through automated systems. The discussion emphasized that successful innovation requires combining technology investments with process improvements to deliver measurable ROI through reduced denials, accelerated payments, and decreased administrative burden.

Shining the Revenue Integrity Spotlight on Third-Party Payers

Sutter Health (Edward Fabi and George Hollcraft)

Sutter Health addressed the growing challenge of surrogacy payers and health share programs that complicate the reimbursement landscape. These alternative payment arrangements often exploit regulatory gaps and create collection challenges for healthcare providers. The presentation provided strategies for identifying these arrangements early, understanding their legal implications, and developing appropriate financial policies to protect organizations while ensuring patients receive necessary care.

Emergency Department Coding Excellence

Spire Orthopedic Partners (Sandra Giangreco Brown)

Emergency department coding presents unique challenges requiring specialized expertise and continuous education. The presentation emphasized the importance of accurate documentation and coding in this high-volume, high-acuity setting where errors can significantly impact both compliance and revenue. Organizations must invest in specialized training for ED coders and establish robust quality assurance processes to ensure accuracy in this critical revenue area.

Implementing a Multidisciplinary Approach to Revenue Integrity

Successful revenue integrity requires breaking down silos and creating truly integrated teams that span clinical, financial, and operational domains. The symposium consistently reinforced that revenue integrity is indeed a "team sport" requiring collaboration across departments. Organizations that successfully implement multidisciplinary approaches see improvements not just in financial metrics but also in clinical documentation quality, compliance rates, and overall operational efficiency.

Looking Forward

The 2025 Revenue Integrity Symposium demonstrated that the field continues to evolve rapidly, driven by technological innovation, regulatory changes, and the imperative to balance financial sustainability with patient affordability. Organizations that invest in comprehensive revenue integrity programs, leverage both technology and human expertise, and maintain strong collaborative relationships across departments are best positioned to thrive in this complex environment. As we move forward, the lessons learned from these industry leaders will guide organizations in building resilient, effective revenue integrity programs that support both financial health and patient care excellence.