DRG Review for Commercial Client
In a recent review of a commercial DRG claim involving a heart procedure and device, with paid charges of more than $440,000, CERIS identified over $95,000 in overpayment because of coding errors that weren’t supported in medical documentation. CERIS achieved these cost savings by leveraging proper documentation and a clinical coding review.
CERIS handles fully/self-insured DRG reviews; our approach includes applying medical records and clinical coding against DRGs and applying machine learning logic criteria to help select claims smarter, improve hit rates, and drive incremental value for our clients across multiple states.
An additional advantage is our strong relationships with release of information (ROI) vendors, helping us drive higher procurement rates. With over two decades of itemized bill procurement experience, CERIS has a longstanding rapport with large providers and health systems.
This case exemplifies a DRG claim paid inaccurately simply because of unsupported primary and secondary diagnosis codes. Due to our clinical validation expertise, CERIS’ review resulted in over $95,000 in findings of excess charges, making a significant impact on the client’s bottom line.