Solutions for Common Pain Points in the Pre-Pay DRG Review Process

Two co-workers sit side by side, pointing at a list of items on a clipboard. The two are animatedly discussing the information on the paper.

“Nothing but good comes from moving to a DRG pre-pay environment”- Kurt Erikson Introduced in the 1980s, a DRG (Diagnostic Related Group) is an important component in today’s health care system. Its purpose in categorizing hospitalization costs and determining how much to pay for a patient’s hospital stay allows health plans to pay predetermined amounts […]

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

Papers and pens on a desk, with a computer monitor and a tablet blurred in the background.

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

Two co-workers sitting in front of a laptop computer that is displaying graphs and charts.

To effectively move inot DRG prepay process, it’s important for health plans to decide which claims they want to work and when. Workflow factors ultimately determine the ability of a plan to manage DRG the prepay process, including but not limited to: Number of staff to review claims Bandwidth of staff Number of claims to […]

Why Expanding Into Outpatient IB Pre-Payment Makes Sense… and Money

Credit card and pen resting on an itemized hospital invoice.

Health plans are working harder than ever to avoid inaccurate claims payments upfront to minimize the cost and resources required to recover over-payments on the back end. Although pre-payment itemized bill review (IBR) is still in its infancy stages of mass adoption, it is proving to be an effective method of helping plans avoid post-payment […]

Shifting to Pre-Pay Itemized Bill Reviews

A black post-it note with the word prepayment written on it in white ink. Around the post-it are $100 bills and a black notebook.

According to the Center for American Progress, payers and providers in the United States spend approximately $496 billion annually on billing and insurance-related costs (BIR). Another study by the National Academy of Medicine estimates that the U.S. spends about twice as much as is necessary on BIR costs. These high costs include claims submissions, billing, […]