Healthcare Revenue Integrity Services

Connecting Documentation, Coding, Compliance, and Reimbursement

Healthcare revenue integrity depends on accurate clinical documentation, coding, medical necessity, billing, and reimbursement working together. When these functions fall out of alignment, the results can include payment inaccuracies, compliance risk, audit exposure, and unreliable information for financial and operational decisions.

PYA helps healthcare organizations evaluate and address these risks. Our work includes documentation and coding audits, medical necessity reviews, and government and payer audit response, supported by statistical analysis, overpayment calculation, independent review, and education. Each engagement is scoped to the issue, the applicable requirements, and the intended use of the findings.

Revenue Integrity at the Intersection of Compliance and Reimbursement

Healthcare revenue integrity is the coordination of clinical documentation, coding, medical necessity, billing, reimbursement, and compliance across the revenue cycle. PYA provides focused review and advisory support to help healthcare organizations assess identified concerns, respond to government and payer audits, evaluate potential overpayments, and develop practical compliance and internal audit work plans.

Our Healthcare Revenue Integrity Services

Coding, Documentation, and Medical Necessity

Documentation and coding audits
Medical necessity compliance reviews
Hierarchical Condition Category (HCC) risk assessments
Ad hoc coding consulting
Teaching hospital coding compliance reviews
Specialty services coding advisory
Coding query assessments
Urine drug screen billing compliance reviews
High-production physician coding reviews

Audit Response, Disclosure, and Overpayment Support

Government and payer audit response
Medicare and OIG self-disclosure support
Statistical analysis and overpayment calculation
Independent Review Organization (IRO) services
Corporate Integrity Agreement (CIA) consulting support
Commercial payer reimbursement dispute analysis and support
Litigation support for payer-provider disputes

Compliance Programs and Strategic Advisory

Compliance and internal audit program work plans
Investigation support
Education and training for staff and leadership
Engagement work plan development and project management
Coding and reimbursement reviews related to physician contracts, documentation, compensation, and productivity
Integration of coding and reimbursement into financial and strategic modeling
Risk-based contracting assessments

Revenue Integrity Review, Response, and Oversight

PYA Managed Care and Reimbursement Advisory Visualization

Targeted Coding, Documentation, and Medical Necessity Reviews

Revenue integrity concerns may involve an individual provider, specialty, service, claim type, or broader population. PYA performs documentation and coding audits, medical necessity compliance reviews, HCC risk assessments, teaching hospital and specialty coding reviews, coding query assessments, and other targeted reviews based on the identified risk. The scope is defined around the organization’s circumstances and the purpose of the engagement.

Audit Response, Self-Disclosure, and Overpayment Analysis

Government and payer audits, potential overpayments, self-disclosure matters, Corporate Integrity Agreements, and reimbursement disputes require careful technical review and clear documentation. PYA supports issue scoping, documentation and coding review, statistical analysis, overpayment calculation, response planning, independent review, and project management. When appropriate, the work may be coordinated with organizational leadership, compliance personnel, and counsel.

Compliance Program Development and Strategic Decision Support

Revenue integrity findings may affect compliance oversight, internal audit priorities, education, physician arrangements, contracting, and financial planning. PYA helps organizations develop work plans, support investigations, provide staff and leadership education, assess coding and reimbursement considerations related to physician compensation and productivity, evaluate risk-based contracting issues, and incorporate relevant findings into financial and strategic models.

The PYA Difference

Over our 40-year history, PYA has consistently delivered high-value advisory services to our national client base. Our team is deployed to develop custom plans using proven approaches and work plans.

Independence

Private ownership means we answer only to our clients, not to third-party investors, giving us the freedom to be thorough and thoughtful in our work. We judge our success by our clients’ success.

Relationships

We value long-term relationships and work hard to maintain them. Our commitment to client relationships and the communities we serve remains constant.