Revenue Integrity Management Services

The vendor is required to provide revenue integrity management services to secure comprehensive, accurate, and compliant revenue integrity services that support charge capture, CDM management, and denial prevention, while aligning with mission to provide high-quality, accessible care and to ensure the organization’s financial sustainability.
a. CDM maintenance, updates, and revenue maximization
•    Perform ongoing review and maintenance of agency CDM to ensure accuracy, compliance, and alignment with current CMS and payer guidelines.
•    monitor and implement coding, and regulatory updates (quarterly and annual).
•    Identify opportunities to capture lost or missed charges within the CDM framework.
•    Policy development: if agency lacks policies, develop policies and processes for effective chargemaster management to optimize revenue while ensuring compliance with regulatory requirements.
•    Provide education and process improvement recommendations for departments utilizing the CDM.
b. Charge capture and reconciliation
•    Develop and oversee standardized charge capture reconciliation processes across inpatient and outpatient departments.
•    Perform routine reconciliation audits between clinical documentation, orders, and billed charges.
•    Recommend workflow improvements to reduce late charges, missed charges, and charge errors.
•    Code discovery: identify discrepancies in codes, revenue codes, and modifiers that have been deleted, replaced, invalid, inactive, or missing; rectify and communicate findings to appropriate stakeholders.
c. Outpatient pre-bill edit review
•    Monitor outpatient pre-bill edits to prevent billing delays and reduce claim rework.
•    Collaborate with him, coding, and billing teams to resolve recurring edit issues.
•    Provide reporting on edit trends and root cause analysis with recommendations for process changes.
d. Pricing and charge strategy
•    Conduct pricing analyses and market comparisons to ensure agency pricing strategy is competitive, compliant, and sustainable.
•    Provide recommendations on charge structure to support both transparency requirements and financial goals.
•    Support agency compliance with CMS price transparency regulations and ensure patient-friendly presentation of data.
e. Outpatient denials prevention and management
•    Analyze outpatient denials to identify documentation, coding, or charge-related root causes.
•    Collaborate with cdi, coding, and revenue cycle teams to create or improve robust processes for managing claims, claim denials, underpayment recovery and implementing corrective action.
f. Coding information for supplies and pharmaceuticals
•    Gather and research appropriate HCPCS codes for supplies and pharmaceuticals.
•    Ensure accurate mapping to charge description master (CDM) line items for compliant billing and reimbursement.
•    Provide guidance to pharmacy, materials management, and clinical departments to maintain coding accuracy.

- Contract Period/Term: 6 years
- Questions/Inquires Deadline: October 3, 2025