CHALLENGES FOR CLAIMS PAYERS
DRG claims present a unique set of challenges for payers ‘claims departments that attempt to identify and correct billing errors by themselves. Whether for those payers who perform their own internal auditing or those who choose to utilize 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 can only be found by experienced coding professionals who are trained to identify and correct them by applying compliant practices and official regulatory guidelines.