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 DRG reviews occur in a post-pay environment, leaving audits outstanding over months and even up to a year, depending on the payer-provider policy.
The idea of moving DRG into the prepay process can seem overwhelming and perhaps even impossible. There are barriers in the current process of reviews that prevent efficient, speedy, and even accurate findings. Despite these barriers, there is a promising way forward that is changing the game of DRG review and allowing payers to efficiently deal with DRG review in post-pay and move the process into prepay, saving time and money while decreasing provider abrasion and lowering costs.
Here are some of the top challenges of a DRG review:
Nurse review fatigue is a real thing! Nurses and coders spend hours reviewing DRGs, looking for coding errors and justifications for services administered. The average DRG medical record is approximately 250 pages. However, DRGs like sepsis are much longer and can easily get to 700-800+ pages.
No matter how many pages, a nurse must manually review each page to complete the review accurately. This process amounts to countless hours, every day, looking through detailed text. Even a DRG with very few or zero errors must be reviewed in full, adding to the fatigue that comes from reviewing hundreds and even thousands of pages.
- Lacking Technology To Support The Process
Previously, there wasn’t the technology available to support the review process. Today, the technology undoubtedly exists and is proven to be the difference-maker. However, most plans still utilize antiquated methods that amount to using a red-ink pen to mark a piece of paper (printed PDF). Today, leveraging technology to support reviews is the single most powerful opportunity available to save valuable time, money, and resources.
The review process comes with a lot of room for interpretation. What guidelines is the plan using, and how robust is the internal policy to support the decisions being made on the review? The more robust the plan, the easier it is to justify the audits. However, the other side of that is that it takes time to learn and know the policy, and in instances of not knowing, it takes time to search and find the policy details. There are often multiple sources that make up the policy, including utilizing industry guidelines, clinical guidelines, white papers, and more. It can be a challenge for nurses and coders to know where and how to access the information they need to make an accurate determination.
- Inconsistencies In Review
Review fatigue, lacking proper technology, and internal policies that are tough to navigate all lend to inconsistencies in reviews. The more inconsistencies, the more appeals from the provider, and the process drags out, eating away at time, money, and resources. Many times, a review isn’t based on one single diagnosis but involves multiple ones. There may be a chronic diagnosis as well as an acute diagnosis, and understanding the nuances of coding for each of these is essential to achieving an accurate review. Jumping from coding for one diagnosis to another and understanding how they may or may not overlap opens the door to inconsistent findings from one DRG to another.
Addressing The Challenges
What’s the possibility of addressing and overcoming these challenges? Let us introduce CAVO®. Our CAVO® solution is a medical record and claim review platform that scales across your entire enterprise and integrates into your workflow, allowing reviewers to review claims in a matter of minutes instead of hours and days.
Our platform takes in images (PDF, TIFF, JPEG, etc.) and then extracts usable data that can be searched via our Google-like search function. Specific information can quickly be found for review via the search function. Searches for common coding errors can also be saved to use on future DRGs, leading to further savings of time and assuring accurate findings.
Another valuable function is a library that allows you to house references such as policies, clinical or industry guidelines, and essentially any references that aid in making accurate determinations within the DRG review. Further time is saved in the ability to save searches that are frequently used, so when a new DRG is uploaded, previous searches can be quickly recalled to help bring a quick decision. This brings a consistency to the review process that prevents further appeals.
Our CAVO® DRG Predict also works in conjunction with CAVO®, leveraging the power of artificial intelligence and automation. There are mounds of information in a medical record, and we’ve developed a way to bring that information to the surface. We have a solution that takes unstructured data and then provides it structure, giving you the exact information you need to review the records.
By leveraging our CAVO® and CAVO® DRG Predict platforms for your DRG reviews, you can move your DRG into a prepay process. How?
- The data extracted from the image file allows nurses and coders to search for specific data, allowing the review to happen in minutes instead of hours.
- Allowing the platform to find the data significantly reduces review fatigue.
- Our best-in-class technology is end-to-end support for the entire DRG review process.
- Utilizing the library, search, and saved search features saves time and effort, bringing efficiency as all of your claims, notes, and reference documents are housed in one place.
- Consistency in review decisions prevents further appeals and quickly resolves the claims issues.
- A 5x productivity lift with our CAVO® platform allows you to do more DRG reviews and faster. This helps meet the prepay deadlines that are dictated by the policy.