DRG/Outlier Compliance Review

Protection Against Submitting False or Inaccurate Claims
Our reviews by RN Auditors and/or Coding Specialists identify potential problems with billing documentation and coding accuracy. Due to the complexity of current charging systems, documentation and billing errors are common and have a wide variation from facility to facility.

Appropriate Medicare and DRG Contracted Payments
The primary objective of our service is to ensure that services are ordered by a physician and provided to the patient according to hospital protocol, documented in the medical record, and billed correctly. Appropriate payment will be ensured and undercoding and overcoding avoided.

Avoid Medicare Outlier Payment Problems
We have a progressive compliance strategy to ensure that billing for Medicare payments for outliers and services is appropriate. Our strategy is designed to ensure the greatest level of scrutiny to help identify potential problems. We will perform a line item review of patient records to determine whether care is reasonable and necessary. We address documentation issues, coding accuracy, and charging in the light of official Federal, State and Institutional guidelines and OIG alerts.

Here is how our service benefits your facility:

• Accurate DRG Assignment
• Appropriate Payments
• Validation of Outlier Payments
• Management and Statistical Report
• Customized Training for Physicians, Coders and Compliance Staff

Sample Review Findings
The following chart reflects the net increased reimbursement for a client Health System. The total financial benefit to the HS for the six-month review was $ 411,573.