/ PRE-PAY / DRG /
Northeastern Regional Health Plan Covering 1M+ Lives Advances DRG Nurse Review Team Productivity using CAVO DRG Validation
THEN
→ Chasing the Records
Before CAVO DRG Validation, 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 the facility on-site.
→ Reviewing the Records
The assigned reviewer accesses the medical record from the appropriate location based on the facility’s preferred delivery method (see above).
If a nurse was performing this review on-site within the EMR, the reviewer could perform simplistic searches. Otherwise, without any search functionality, nurse reviewers paged through records looking for data points such as a BMI or lab value relevant to that case’s determination – often spending hours to locate that specific information
It All Depends On the Case
Inpatient charts typically vary significantly in length. For this plan, charts typically range from 125 pages for a standard newborn delivery to 5,000+ pages for a complex inpatient hospital stay spanning multiple months (or “chubby charts” as the review team likes to reference these!).
Therefore, the time to access and review varies significantly dependent upon the case.
→ Summarizing Findings
Next, the nurse made a determination, typed a summary in a departmental tool specific to discrepancy reports, and sent the results to the hospital.
→ Meeting CAVO
Upon seeing the CAVO DRG Validation demo, the ability to search within the medical record using predefined or user-defined searches caught the team’s attention as an immediate solution to their biggest medical record review pain point. They had found a better, more efficient way to find those decision data “needles” in the “haystack” of a large inpatient chart.
NOW
→ Chasing the Records
The team continues to gather the records according to each facility’s processes.
How CAVO® Connect Can Solve Record Chasing
Our experience with vendors and payers indicates chasing a medical record typically costs between $25 and $95 and can also require 2 – 6 weeks to obtain. CAVO Connect is a cutting-edge technological solution to this costly, lengthy request-and-deliver medical record information process between providers and plans.
CAVO developers have built validated apps within the largest acute care EMRs to immediately obtain the required medical record documentation along with the clinical data, at scale, in order to review, make any changes, and then reimburse the claim timely and appropriately.
→ Reviewing the Records
The review team opens the medical record within CAVO, regardless of the facility’s delivery method. The entire team utilizes CAVO DRG Validation to perform DRG reviews with ongoing support from the CAVO Client Experience team. Plus, departmental leadership has leveraged CAVO to develop review best practices and standardize the intake-to-QA process.
Additionally, the Client Experience team leads monthly team meetings that often include increasingly complex search tips and tricks designed to further enhance DRG review productivity gains. For example, in a recent monthly meeting, the CE team shared an example from a prior month’s case where the reviewer searched Operative report, which generated 294 results from the 423-page medical record. However, searching “Operative note” – with the quotations included – generated 5 results and surfaced specific information the reviewer needed to make a determination.
→ Summarizing Findings
The nurse reviewer uses the CAVO search functionality to quickly find the needed decision data, regardless of the record’s size. While corporate policy still requires using the discrepancy reporting tool for summaries, departmental leadership is eying the CAVO Letter functionality, especially with recent enhancements that could further improve productivity.
CAVO DRG VALIDATION RESULTS
CAVO has transformed the way medical record reviews are completed today within this health plan. After the initial training and adoption period, the DRG review team is completing reviews much more quickly, and the department’s leadership is excited by the progress illustrated by the team’s increasingly complex CAVO search ideas and questions. As a result of the associated productivity and efficiency lifts, the team has improved its overall case workload, which has increased revenue and provided bandwidth for pre-pay review initiatives – without additional FTEs.
Additionally, departmental leadership is anticipating a DRG review process that is further streamlined following the upcoming implementation of the CAVO-TruCode integration.