DRG Claims Management provides an innovative approach to DRG claims validation and recovery of confirmed over-payments on behalf of the segment of payors that pay claims based on DRG methodology: Medicare Advantage, Managed Medicaid, Commercial Plans, IPAs, TPAs, ASO/MSOs, Exchange Plans, and PACE programs. Additional wrap around services are also offered, including:

  • Integrated clinical validation reviews and findings reports by our physician team partners to provide a best of breed comprehensive approach to clinical documentation, coding errors and DRG assignment inaccuracies.
  • Identification of cases requiring medical necessity and re-admission reviews
  • Cost outlier reviews: DRG coding analysis and medical necessity validation of length of stay / level of care of each billed day, and forensic review of itemized charges that drove the outlier status, with the goal of reducing or eliminating the outlier surcharge
  • Third party “tie breaker “peer reviews for unresolved DRG claim disputes
  • Claims support services: Our team’s knowledge of claims systems and procedures allows us to support our clients with claims analysis functions that require a strong DRG claims understanding
  • HCC documentation reviews for risk scoring: Our CRC credentialed Certified Risk Coders perform both inpatient and outpatient documentation reviews to identify HCCs for accurately optimized risk scoring, and identify areas where additional documentation is required.