4 Common Health Plan Challenges in the DRG Claims Review Process

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If you’re an executive at a health plan you likely spend a fair amount of time and energy thinking about minimizing provider abrasion. But what about the challenges you face on the payer side of the equation? Health plans have long struggled with inefficiencies that compromise provider relationships and hinder business performance. To illustrate those […]

[WEBINAR] 50%+ Faster Health Plan DRG Claim Reviews

50%+ Faster DRG Claim Reviews Webinar

WEBINAR REPLAY 50%+ Faster DRG Claim Reviews Health plan industry veterans share three best practices for improving DRG claim review efficiencies. Hear recommendations you can apply for almost immediate productivity increases. Create a scalable DRG review process by applying three principles Filter claims with the highest potential to align your team’s time Reduce cost per […]

Plan Client Success – CAVO DRG Validation Client

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/ PRE-PAY / DRG / Northeastern Regional Health Plan Covering 1M+ Lives Advances DRG Nurse Review Team Productivity   THEN   → Chasing the Records The record intake team gathers the medical records, depending upon facility, by: Utilizing third-party electronic delivery services, Obtaining encrypted disks from the facility, Accessing the facility’s electronic portal, or Visiting […]

Plan Client Success – CAVO Prepay Itemized Bill Reviews

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/ PREPAY REVIEWS / ITEMIZED BILL REVIEWS /   Regional Health Plan Decreases Pre-Pay Hospital Bill Review Time by 500+% Per Case    THEN   This regional health plan has an internal team of RNs performing hospital bill pre-pay reviews. Nurse reviewers previously either:  requested the itemized bill (IB) directly from the provider based on […]

Plan Client Success – CAVO Cost Containment Readmission Reviews

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/ POST-PAY /   Cost Containment Readmission Reviews Unit Experiences 6:1 ROI During CAVO® Kick-Off Training   THEN   Client reviewers had to first locate the records associated with the case. Next, reviewers located appropriate documentation within the case (e.g., ED notes, Admission notes, H&P) to find presenting symptoms and reasons for admission. Nurses then […]

Plan Client Success – CAVO Post-Pay DRG Validation

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/ POST-PAY / DRG /   Large National Payer’s Post-Pay DRG Validation Team Achieves 300+% Productivity Increase with CAVO   THEN   This large national payer applies enterprise rules, edits, and analytics to all post-pay DRG claims to pinpoint “suspects” for potential overpayment, which are then reviewed by a team of RNs. Analytics were performed […]

Plan Client Success – CAVO Prepay DRG Reviews at Regional Payer

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/ PRE-PAY / DRG /   Regional Health Plan’s Pre-Pay DRG Review Team Uses CAVO to Increase Productivity by 200%   THEN   RNs performed DRG validation reviews primarily from providers’ EMRs. Reviews were a page-to-page comparison (often averaging 500+ pages per case) within slow systems with cumbersome navigation. Once RNs located decision information, they […]

Plan Case Study – Using CAVO for Medical Necessity Reviews

Medical necessity appeals

/ Post-Pay Reviews / Medical Necessity Reviews /   THE CASE   Patient is a 50-year-old male who had a neurostimulator placed for pain control related to chronic back pain and right lower extremity numbness. He is a former police officer who was injured while on duty with nine subsequent back surgeries resulting in post […]

Plan Case Study – Using CAVO for DRG Reviews

Payer CS DRG

/ POSTPAY REVIEWS / DRG REVIEWS /   Using CAVO for Searching a Medical Record   Patient is a 35-year-old female with a history of prosthetic heart valve who presented to the Emergency Department complaining of rectal bleeding and heavy menstrual period for six days. She was especially concerned because she takes Coumadin to help […]

Digitally search medical records for claims reviews

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Check Out Our 1-minute CAVO Answers Functionality Video. See how CAVO Answers enables you to type search terms or phrases, utilize pre-defined searches, create and sort by tags, and receive relevance-ranked results.