Drg Claims Management

DRG Claims Management provides an unprecedented, customized pre-payment DRG claims review services for any DRG claims payer, especially Medicare Advantage and Medicaid Managed Care plans as well as other commercial payers. We provide our services to dozens of payers on a national level and have experience with providers in all 50 states and Puerto Rico. Our expertise and proven results are achieved consistently across all DRG methodologies inclusive of APR-DRG, MS-DRG, AP DRG and all federal, commercial, and state specific pricing schedules. We’ve designed state-of-the-art workflow applications and developed a proprietary algorithm-based auditing process screen and identify claims with the highest potential for recovery results. We review medical record documentation for the accuracy of the assigned DRG and payment based on correct application of regulatory mandates and official guidelines and conventions. - all at no financial risk to our clients. • Our team is highly specialized in the intricacies of DRG methodology and coding and we find coding errors and overpayments of up to 60% of a claim’s original billed amount. The majority of overpayments are found in the mid-range of claims priced from $10,000 to $80,000. • Unlike the majority of our competitors, we preserve important provider relationships and maintain the professional dialogue until we obtain a signed provider confirmation of the DRG revision. • Provider “sign-offs” effectively eliminate costly appeals and overturning of the audit determination, thereby relieving the health plan of addressing resolution in a formal and resource-consuming appeal process. • On average, we achieve a yearly savings of $3-6 million of verified over-payments for every 100,000 members in a typical DRG payment environment, relative to the Plan’s demographics and membership case mix. Savings for Managed Medicaid/Family/Children’s plans is the range of $3M per 100k members.