Artificial Intelligence in DRG Review: Streamlining Reviews and Enhancing Efficiency
Artificial Intelligence has made significant advancements to payment integrity and the DRG reviews process. By leveraging AI technologies, such as natural language processing (NLP) and machine learning (ML) algorithms, healthcare organizations can streamline the review process, improve accuracy, enhance efficiency, and better manage the cost of quality care for their constituents. Building the Model: Preprocessing […]
Shifting DRGs ‘to the left’
DRGs play an important role in the healthcare landscape; their significance, challenges, and potential to enhance revenue integrity programs in an ever-evolving market are unlike other patient categorization systems. How a payer approaches DRGs can reduce administrative burdens and refine provider relationships, and when combined with pre-pay claim review tools, they can be transformative to […]
Increase DRG Review Productivity for Your Staff
The administrative burden is difficult to manage in the DRG review claims process. With millions of patients being treated on a daily basis, the sheer number of medical records is overwhelming and can block health pans from being able to move into pre-pay DRG reviews. Consider that the vast majority of DRG reviews are still […]
DRG Validation and an AI Approach to Sepsis
CAVO® DRG Predict Video Series | DRG Validation In this video series, our Principal Scientist Lance Hahn, Ph.D., and our Machine Learning Engineer, Cam Carver, discuss medical record documentation and technology, including machine learning, natural language processing, artificial intelligence, named-entity recognition, and how these technologies are used for DRG validation and how to identify sepsis […]
Solutions for Common Pain Points in the Pre-Pay DRG Review Process
Introduced in the 1980s, a DRG is a crucial component of today’s healthcare system. Most DRGs today are reviewed in a post-pay environment – providing challenges for both provider and payer alike. For the provider, the post-pay DRG review comes with considerable abrasion, often requiring service fees already collected to be returned to the payer […]
Moving to Prepay DRG Reviews
Let’s face it: the modern-day DRG review process is laborious, cumbersome, and quite often…exhausting. Every step from requesting the record to exchange, to preparing the document to review, and then notifying the provider of downgrades or changes takes time, effort, and valuable resources. Due to the time and resources required, most Prepay DRG Reviews occur […]
Moving DRG Into The Prepay Process: Record Exchange Challenge
So you’ve selected the DRGs that you want to review…now what? Next in the process is the record exchange. One of the biggest hurdles to moving DRG reviews into the prepay process is the actual record exchange between payer and provider. Traditionally, all too often, the amount of time required to execute the record exchange […]
Moving DRG Into The Prepay Process: The Importance of Claim Selection
To effectively move into DRG prepay process, it’s crucial for health plans to decide which claims they want to work and when. Workflow factors that ultimately determine the ability of a plan to manage the DRG prepay process, include but are not limited to: Number of staff to review claims Bandwidth of staff Number of […]
Health Plan Challenges in the DRG Claims Review Process
Combating Common Health Plan Challenges 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 health plan challenges you face on the payer side of the equation? Health plans have long struggled with inefficiencies that compromise provider relationships […]