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DRG Claims Auditing

Medical Cost Containment

DRG Claims Auditing

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DRG Claims Service provides expertise in identifying, correcting, and obtaining verified changes to DRG coding errors.  SFUR licenses a customized pre-payment DRG auditing program that flags potential problem claims that are reviewed initially by nurses and if a clinical review is required, physicians perform the full clinical chart review.   

SFUR Ensures DRG Claims compliance and integrity with provider-verified audit results with a customized service model for managed care payers.

Our clinical and business leadership brings decades of experience in cost containment in every payer-based and managed care setting.

Summary

Since the introduction severity-based MS-DRGs, certain hospital appear to be over-coding to obtain higher payments. This offering helps payers increase their auditing prowess.

Ensuring DRG Claims compliance and integrity with provider-verified audit results with a customized service model for managed care payers.

  • Our audit processes and communications reflect our management team’s deeper understanding of the respective viewpoints and cultures of both providers and health plans.
  • Our clinical and business leadership brings decades of experience in cost containment in every payer-based and managed care setting.
  • We stand out among our competitors by building our entire business around our unsurpassed expertise in identifying, correcting, and obtaining verified changes to DRG assignment errors.

Example

For every 100,000 members in an average Medicare/Medicaid DRG payment environment, there are $3-6 million in savings achieved.  On average the reduction per claim is between 25% to 65% of the originally billed DRG price for successfully corrected coding errors.

This service is offered on percent of savings to the payer. If savings are not achieved, the payer is not charged.

The cornerstone of our success in resolving DRG coding errors and ensuring a smooth recovery process is our commitment to delivering an appeal-safe process.

  • We do this by consistently obtaining a provider-signed agreement form which authenticates a hospital’s confirmation of the DRG re-assignment recommended by DRG Claims Management.
  • We deliver a complete and accountable process, which is culminated with either a validation of the accuracy of the originally billed claim OR a provider-signed agreement to our recommended changes.
  • We go beyond the common industry practice of identifying coding errors that typically get reported as “final audit results.” Instead, we actively pursue a verified agreement to our findings beyond the typical “30 day attempt” timeframe implemented by many industry vendors.