It’s fair to say that “not all DRG vendors are created equal.” Despite overlapping marketing efforts, there are two general categories of DRG auditing products: those that primarily serve provider hospitals and those that are designed to identify overpayments on behalf of health plans and payers. Just as an attorney typically specializes in defense or plaintiff representation, auditing vendors specialize in the unique needs, cultures and priorities of the parties they respectively serve.

Even within the category of payer-based vendors, there is also a wide range of approaches to DRG auditing and overpayment identification. The three major sub types are:

  1. Companies that primarily employ data mining and editing approaches: These companies often charge on a pm/pm or per claim basis, or a combination of pm/pm and a percentage of identified savings.
  2. Coding guideline-based auditing services: These programs employ credentialed coding professionals and validate coded diagnoses in accordance with established coding conventions and the Official Guidelines for Coding and Reporting. A small minority of these programs also obtain a provider-signed agreement to the vendor’s recommended changes.
  3. Companies that employ a combination of both data mining and clinical approaches: Typically, the coding guideline based portion of the approach is limited by broader selection filters and often includes a greater emphasis on the accuracy of physicians’ clinical documentation of diagnoses, more so than it does the intricacies of coding guideline compliance.

DRG Claims Management employs the second type of auditing program noted above, Additionally, we extend our scope of services to our physician review team to produce clinical validation findings for situations where the identified issues are unsubstantiated clinical diagnoses documented by treating physicians and therefore exceeds the scope of coders. Keeping in mind that the authority of assigning and correcting DRG coding lies within the provider’s Health Information Management coding department, DRG Claims Management implements a coding guideline-based model that will have the greatest chance of achieving cooperation and written agreement by the provider hospital. Such collaboration is instrumental in preserving provider – payer relationships as well as in reducing and eliminating burdensome denials and appeals. Our results prove that our coding compliance model supported with physician clinical validation when needed will produce verified savings that will yield the best results in all aspects of what payers hope to achieve.