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.

Errors are typically not found by applying everyday logic or intuitive means such as validating diagnoses known to utilization management review documents or other claims data. Instead, correcting the errors require a complex and technical approach of selecting potential errors based on guideline based criteria and a multitude of suggestive technical factors. Recommendations for correction are arrived at by applying The Official Guidelines for Coding and Reporting set forth by the four regulatory cooperating parties ICD-10 (CMS, AHA, AHIMA, and NCHS.)  Examples of such errors include the incorrect sequencing of diagnoses, improper use of combination codes and excluded codes, non-adherence to disease and condition-specific guidelines, misapplying updated procedural codes, and not referencing the precedent rulings of the AHA Coding Clinics. 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 payers.