REVENUE INTEGRITY OPERATING SYSTEM
Control Tower for Specialty Infusion
Oncology · Rheumatology · Neurology · Dermatology
A governance architecture that enforces end-to-end integrity from clinical intent to final payment.
THE GOLDEN THREAD
One continuous chain of accountability
Validated at every transition by the Control Tower
Intent to Treat
→
Prior Authorization
→
Procurement & Scheduling
→
Administration
→
Coding & Charge
→
Claim
→
Payment & Variance
CENTRAL GOVERNANCE LAYER
REVENUE INTEGRITY CONTROL TOWER
Claim Release Authority • Continuous Governance • Learning System
VALIDATE
→
DECIDE
→
HOLD
→
RELEASE
CLINICAL INTEGRITY
Medical necessity, documentation completeness, administration accuracy, structured EHR fields
FINANCIAL INTEGRITY
Charge capture reconciliation, NDC/J-code match, wastage, expected reimbursement vs contract
CONTRACT INTEGRITY
Payer rules, site-of-care, 340B, buy-and-bill margins, underpayment detection
REGULATORY INTEGRITY
LCD/NCD compliance, lot traceability, biosimilar rules, audit readiness
OPERATIONAL SPOKES — FEEDING THE TOWER
SPOKE 01
Scheduling & Access
- Verification of Benefits (eligibility, coverage, deductible status) — performed prior to prior authorization
- Chair utilization & patient flow
- Authorization expiration management
- Drug ordering & inventory alignment
- Site-of-care & staffing coordination
SPOKE 02
Pharmacy & Inventory
- NDC-specific dispensing matched to authorization
- Wastage, cold-chain & vial-sharing rules
- 340B & buy-and-bill reconciliation
- Biosimilar validation & lot traceability
- Same-day charge generation
SPOKE 03
Nursing & Clinical
- Structured start/stop times in EHR
- Sequential vs concurrent infusion documentation
- Route, dose & interruption accuracy
- Clinical notes supporting medical necessity
SPOKE 04
Coding
- J-code & NDC validated per payer policy
- CPT units from documented time
- ICD-10 match to authorization
- Specialty-specific bundling rules
SPOKE 05
Billing & Finance
- Daily charge lag monitoring
- Authorization field population
- Expected reimbursement benchmarking
- Pre-submission scrubbing & variance tracking
KNOWLEDGE ENGINE
- Dynamic payer policy knowledge base (medical policy, LCD/NCD, step therapy, quantity limits)
- Site-of-care, biosimilar & formulary rules
- Contract terms & reimbursement methodology
- Real-time updates on authorization & coverage changes
CONTINUOUS LEARNING LOOP
- Denials, appeals, underpayments & charge leakage feed upward
- Root cause analysis performed at the Tower
- Updated rules and training pushed to all spokes
- Monthly denial pattern reporting by drug, payer & reason code
TWO LAYERS OF CONTROL
🟨 PREVENTIVE CONTROLS
- Prior authorization completeness validation
- Clinical documentation & medical necessity checks
- NDC / J-code / units cross-validation
- Charge capture reconciliation before release
- Contract & site-of-care rule enforcement
🟩 DETECTIVE CONTROLS
- Denial trend analysis by drug, payer & reason
- Payment variance & underpayment detection
- Post-payment audit readiness & root cause
- KPI dashboards and feedback to spokes