/ POST-PAY / DRG /
Large National Payer's Post-Pay DRG Validation Team Achieves 300+% Productivity Increase with CAVO
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 on claims that had been adjudicated, and then medical record requests were sent to the providers. Once records were received (via fax, mail, portal, email, etc.), the RNs reviewed claims to determine whether documentation supported the provider billing. Traditionally, the received records were imaged (and therefore not searchable), and the RN completed page-by-page reviews to validate the DRG. These reviews took a tremendous amount of time, and given constraints of time and internal clinical resources, aged claims were distributed to vendors.
The health plan selected CAVO® to increase internal DRG post-pay reviews and decrease vendor spend – without adding FTEs. Leveraging CAVO technology, their nurse reviewers instantly find information within the medical record and determine the opportunity (i.e., finding or no finding). For claims with findings, this payer completes reviews in their entirety within CAVO by utilizing our “Review” and “Letter” functionalities. Specifically, RNs quickly select relevant pages within the record – highlighting and annotating as needed – then create a summary for internal escalation or external distribution back to the providers.
Six months post-CAVO training, this large national payer has increased total reviews by 300+% and trended vendor spends significantly downward. End-users are praising their experiences, particularly as they become more savvy with our technology. (Periodic check-in sessions with their assigned CAVO account manager includes progressively complex searching tips plus Q&A.) Nurses are navigating a single platform to conduct reviews, and the quality assurance team is able to drill-down into cases and review user audit logs to provide more insightful coaching to their remote nurse review team.