Revenue Integrity & Charge Capture

You sit between the department and the bill. Care gets delivered all day by people who are not thinking about charges — an infusion that ran longer than it was scheduled to, a second implant opened after the first one did not fit, a drug drawn from a vial with some left over, observation hours that begin at one time in the nursing note and another time in the order. Your job is to find what was done and never charged, and to find the charges that went on the account and should not have. You work the accounts sitting in bill hold, reconcile department logs against what actually posted, chase the late charge that arrives after the claim has already gone out, and answer the department manager who wants to know why their revenue looks soft this month. When something is wrong in the other direction — a charge with no documentation under it — you take it off, and then you explain why.

You own the chargemaster. Every line carries a description, a code, a revenue code, a price and a department that considers it theirs, and the whole file has to move when the code sets move — the procedure code set turns over at the start of the calendar year, the level II supply and drug codes run on a quarterly cycle, the diagnosis and inpatient procedure sets change in the autumn, and the outpatient payment rules shift in between. A code gets deleted and the line keeps billing until somebody notices. A department stands up a new service and builds the line the way it thinks the line should look. Prices have to hold a defensible relationship to each other and to what the service costs. Then you publish: the machine-readable file of standard charges in the format the rule specifies, and the consumer-facing display of shoppable services, refreshed on schedule and reachable by someone who does not know your website. Sooner or later a reporter, a competitor or an employer runs your published file against somebody else's and asks you about a line nobody has looked at in years.

You know what the contract says the claim was worth, and you check what actually arrived. The remittance posts, the contractual adjustment writes itself off, the account balances to zero, and unless someone looks, a short payment is indistinguishable from a correct one. So you model expected reimbursement out of the terms — the case rate, the per diem, the percentage of charges, the outlier and stop-loss language, the implant and high-cost drug carve-outs, the lesser-of clause everyone forgets is in there — and compare it against what the payer actually allowed. When there is a difference you have to work out whose it is: the contract was loaded wrong on their side, the rate version is stale, the carve-out never applied, the outlier was calculated off the wrong basis, or your own expected-payment model is the thing that is wrong. Then you take it back to the payer, and you take the pattern to whoever negotiates the next agreement.