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.