Ensuring compliance and integrity with provider-verified audit results.
We designed a customized service model for managed care payers. Our audit processes and communications reflect our management team’s deeper understanding of the respective viewpoints and cultures of both providers and health plans. Our clinical and business leadership brings decades of experience in cost containment in every payer-based and managed care setting. We stand out amongst our competitors by building our entire business around our unsurpassed expertise in identifying, correcting, and obtaining verified changes to DRG assignment errors.
The cornerstone of our success in resolving DRG coding errors and ensuring a smooth recovery process is our commitment to delivering an appeal-safe process. We do this by consistently obtaining a provider-signed agreement form which authenticates a hospital’s confirmation of the DRG re-assignment recommended by DRG Claims Management. We deliver a complete and accountable process, which is culminated with either a validation of the accuracy of the originally billed claim OR a provider-signed agreement to our recommended changes. We go beyond the common industry practice of identifying coding errors that typically get reported as “final audit results.” Instead, we actively pursue a verified agreement to our findings beyond the typical “30 day attempt” timeframe implemented by many industry vendors.
Our results speak for themselves. More than 95% of the audits we perform result in a “provider-signed agreement” at no financial risk to our clients. We have achieved yearly savings benchmarks of $5 - 8 million of verified over-payments for every 100,000 members in a typical Medicare / dual eligible / Medicaid DRG payment environment, relative to the Plan's demographics and membership case mix. On average, the reduction per claim is 30 – 60% of the originally billed DRG price for successfully corrected coding errors. We do not inundate providers with cases that are easily disputable. We avoid struggling over "gray areas" that often can not be resolved and lead to an eventual appeal, which increases provider cooperation.
We ensure that your health plan’s priorities are understood and well-represented in the course of the DRG auditing program to ensure effective outcomes. Our service model inherently respects and protects your valued provider relationships. We achieve this by prioritizing your provider relationships are of foremost importance and all efforts and communications reflect our commitment toward mutual respect and cooperation. Our policy of obtaining provider-confirmed results further supports this and goes a long way in preventing erosion of the relationship as well as serving as a useful leverage point in provider contract discussions.