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Challenges for Claims Payers

Challenges for Claims PayersDRG claims present a unique set of challenges for claims departments that attempt to identify and correct billing errors by themselves.  Whether for those payors who perform their own internal auditing or those who choose the claims to be referred to a consultant or vendor, the complexity and counter-intuitive nature of DRG methodology often results in claims departments overlooking many of the mid-priced claims where coding errors predominate. Typically audit triggers for high cost claims will fail to find the bulk of coding errors that experienced coding professionals are trained to identify and correct.  Errors are typically not found by applying everyday logic or intuitive means such as validating diagnoses known to utilization management review data or other claims data. Instead, the errors are of the much more complex and technical nature of applying official coding guidelines set forth by the four regulatory cooperating parties for ICD-9-CM and ICD-10 (CMS, AHA , AHIMA, and NCHS) such as the correct sequencing of diagnoses, combination codes, excluded codes, disease and condition specific guidelines, applying updated procedural codes, and referencing the precedent rulings of the AHA Coding Clinics, to name some examples. The complexity and sheer volume of rules require the formal education and expertise of Health Information Management Coding Professionals who possess additional credentials that validate their competency with DRG coding and validation.  This is the proven level of skill that DRG Claims Management brings to health plan payors.
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