Here is a practical framework for achieving effective charge reconciliation within the acute care environment. It outlines a sustainable, two-tiered strategy that balances daily departmental charge reviews with targeted organizational audits to ensure compliance, accuracy, and financial integrity across service lines. By connecting the operational aspects of departmental monitoring with the analytical practices of revenue reconciliation and clinically driven charging, the piece emphasizes shared accountability between clinical and financial teams. Department leaders and finance professionals can use these guidelines to strengthen charge capture processes, minimize revenue variances, and maintain alignment with evolving organizational and system-level reporting standards.
Effective charge reconciliation is foundational to maintaining financial accuracy and operational integrity within the acute care setting. Given the high volume of daily transactions across multiple service lines, auditing every charge individually is impractical for most organizations. A more sustainable model combines daily departmental charge reviews with targeted auditing of sample encounters at the organizational level. This dual approach ensures that departments remain accountable for their own charge generation processes while providing a higher-level validation through centralized revenue review—ultimately supporting compliance, financial performance, and data integrity across the facility.
Ideally charges should be audited for each encounter to verify that everything is correct. Realistically this is unlikely due to the sheer volume of charges that can be generated for even a small facility each day. Instead, it would be better to have each department audit their own charges on a daily basis, and then have auditors check charges for a small sample of patient encounters. Using this two-prong approach reduces the workload to a more manageable level that can be sustained by most facilities.
Departments should be checking their charges to ensure that all expected charges are shown on a daily basis. It is recommended that at least the basic auditing be handled at a department level because the departments will be most familiar with what charges should be generated. At a high-level minimum, the departments should be tracking daily volume of charges to get a view of how many charges are coming through; if kept up over the course of a year or so, the view should show if there are unexpected dips in volume that may be due to problems with the building. At a detailed level, the departments should have a good view of what orders have been placed and be able to verify that charges were created correctly. Departments should also combine this with a clinical review, because what happens clinically will affect the charges.
Department level audits should track and fix issues on a day-to-day basis. At the organization level, auditors should pull a sample set of encounters and audit them to ensure all charges were generated correctly. This type of audit can be combined with a coding audit and general check of the record for consistency and accuracy to ensure that all relevant policies and procedures for the site are being followed.
Revenue Reconciliation Review
When reviewing the revenue that posted to a specific cost center, there are many reasons why one could see a variance (+/-) from the baseline revenue metrics. The Revenue Cycle reports are only showing revenue that Posted to the Patient Accounting billing system. Any charges that were held up or suspended before making their way to the billing system will not be shown in this report until the charge reaches a Posted status. The Posted date of the charge will be the Activity Date is one of the report parameters in all our revenue related reports. It is possible that the Posted date and the Service Date can be different if the charge was Suspended or if the documentation that drove that charge was backdated in the system. Another reason a department/cost center could see a variance would be due to an irregularity in scheduled exams or tests. To understand if your department has the correct output of charges for a given day, you need to understand what the input was (how many were scheduled/ordered/completed). The clinical reports discussed in the service line specific to each service will allow a department leader to understand what was clinically performed. This should correlate to what the department charged for and is showing on the revenue reports for their department/cost center. Not all charges are hardcoded in the charge master. Any charge and workflow that involve soft coding procedures or a coding review process will also impact on the time at which certain charges are posted on an encounter. Understanding this process and how it will impact when you are able to report off that revenue for your department will be an important factor for some department/cost centers more than others.
In order to ensure a healthy financial revenue stream for your department, it is imperative that you understand how and what charges drop from documentation and what the revenue routing mechanisms are for your cost center. It is critical for each department leader to understand and take ownership in the Clinically Driven Charging methods. Any changes to documentation, instruments, machines, or locations all can impact on how a cost center is receiving their revenue. Again, the legacy method of using the CDM to route revenue to your cost center is a thing of the past. To better understand how your cost center is getting credit for which charges, each service line has to make a department/cost center specific CDRC aid that is meant to guide department leaders with understanding how to justify their revenue for a given timeframe.
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