Case study: The impact of prospective DRG validation
As the cost of inpatient care continues to rise, ?improving payment integrity for these claims has become a paramount concern for health plans. However, a significant number of these plans exclusively employ post-payment reviews, which can introduce obstacles in the process of reclaiming funds from overpayments and result in both provider dissatisfaction and member discontent.
That’s why one regional plan partnered with Cotiviti to implement prepay DRG review, which is designed to complement retrospective paid claims approaches while increasing recovery rates, elevating medical record receipt rates, and reducing administrative costs by as much as 15%.
Read our new case study to learn how prospective DRG review:
Discover how Clinical Chart Validation can benefit your organization and provider network by enhancing the efficiency and effectiveness of DRG reviews without compromising on quality.
About the author
Cheri oversees the operation and strategic direction of Cotiviti’s prospective and retrospective Clinical Chart Validation solutions. As a tenured member of this business unit, Cheri leads a team of clinical and coding professionals, product specialists, and medical directors and brings valuable hands-on, day-to-day experience with Cotiviti's portfolio of clients. Before joining Cotiviti, Cheri spent more than 20 years working with health plans, health systems, employers, and government agencies to improve their payment integrity, contract and policy compliance, talent acquisition, and care management practices.
Healthcare Reimbursement Attorney | Managed Care Contracting | Advocate for Providers & Navigating Complex Claim Issues | Audit Defense and Appeals
11 个月Prospective DRG validation is holding up cash flow unnecessarily and applying coding guidelines incorrectly. Reviewers should be trained and skilled to consider all guidelines to determine if there is error versus clipping text that, in isolation, suggests an overpayment. The tremendous burden of Cotiviti’s DRG validation reviews does not improve coding accuracy; it withholds and delays payment.
President and Founder of BAC10 Solutions, LLC.
1 年Cotiviti could have a positive impact on DRG validation reviews if they understood and followed coding guidelines.
Healthcare Reimbursement Attorney | Managed Care Contracting | Advocate for Providers & Navigating Complex Claim Issues | Audit Defense and Appeals
1 年I promise, it does not reduce provider abrasion.
Health Care Management Consultant
1 年Now I know why this company has grown so quickly!