Medical Revenue Integrity Solution
Software solution enhancing medical revenue integrity for hospitals, streamlining coding processes and managing outstanding revenue.
The Challenge
Revenue Integrity Partners works with US hospital systems to identify and recover revenue lost to incorrect medical coding, underpayments from insurers, and missed charge opportunities. Their analysts were doing this work manually — pulling patient encounter data from hospital EHR systems, cross-referencing against payer fee schedules in spreadsheets, and tracking recovery cases in a shared email inbox. The process was slow, inconsistent across different hospital clients, and made it impossible to show clients a clear view of how much revenue was being recovered. Analysts were spending more time managing spreadsheets than reviewing cases.
Our Solution
We built a case management and analytics platform that ingests coded encounter data from hospital EHR exports, applies rule-based and heuristic flags to surface likely undercoding, underpayment, or missed charges, and presents them to analysts as a prioritized work queue. Each case shows the encounter details, the current code, the suggested alternative code with clinical rationale, and the estimated revenue impact. Recovered and pending amounts are tracked per case and rolled up into client-level dashboards showing recovery performance. Integration with the most common hospital billing systems allows corrected claims to be submitted directly from the platform.
Our Approach
Revenue Integrity Rules Engine
Worked with clinical coding experts to translate their manual review heuristics into a structured rules engine. Rules flag encounters based on DRG-to-procedure mismatches, secondary diagnosis omissions, and payer-specific coding patterns known to result in underpayment. Rules are configurable per payer and client, and new rules can be added by the clinical team without code changes through an admin interface.
EHR Data Ingestion Pipeline
Built a data ingestion pipeline supporting HL7 FHIR and flat file exports from major hospital EHR systems including Epic and Cerner. The pipeline normalizes encounter data into a unified schema, validates for completeness, and processes batches nightly. Data is encrypted at rest and access is role-scoped per analyst to ensure HIPAA compliance.
Analyst Work Queue & Case Management
Built the core analyst interface as a prioritized case queue sorted by estimated revenue impact. Each case opens to a full encounter view with the flagged coding issue, suggested correction, and a field for the analyst's clinical rationale note. Cases can be escalated, sent back to the hospital coding team, or marked as resolved with the outcome captured for reporting.
Client Reporting Dashboard
Delivered a client-facing dashboard showing total opportunities identified, cases resolved, revenue recovered, and outstanding cases by status. Built a monthly PDF report with configurable date ranges exportable for client presentations. Recovery trends are visualized by payer to highlight systemic underpayment patterns from specific insurers.
"Our analysts can now review three times as many cases in a day and the quality has gone up because they're focused on medical decisions, not spreadsheet management. Clients can see exactly what we've recovered and how."
Let's Build Together
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