Healthcare industry statistics indicate payers often get it wrong in DRG reimbursement, inappropriately downgrading DRGs for sepsis, acute respiratory failure, acute kidney failure, blood loss anemia, and pneumonia.
Now: Manual DRG reviews
Payment integrity coders and/or nurses determine appropriate DRG for reimbursement by sifting through mountains of paper sent by the provider.
Plans have varied processes for verifying – and confirming – the diagnosis billed aligns with treatment during hospital confinement.
Next: Search-assisted reviews
Coders and/or nurses use technology to pinpoint needed information and make decisions 300+% faster – prepay or postpay.
Prepay reviews: Improved TATs leveraging a pre-defined search library for even quicker decisions and postpay audit avoidance
Postpay reviews: Trend which savings are realized immediately or extrapolated in future savings
KEY FUNCTIONALITY FOR DRG VALIDATION
Library of 100s of available complex “and”, “or”, and “not” statements designed to efficiently pinpoint DRG validation information