The Evolving Role of DRG Audits in Payment Integrity

Greg Dorn, President & Mark Johnson, SVP Product Management

May 09, 2024


In the landscape of healthcare, the past 12-months have been marked with increasing AI advancements, medical inflation, cost pressures, an ongoing demand for affordability, and workforce challenges for payers.

As we look at healthcare finance and management, one thing that stands clear is the need for rigorous, yet adaptive payment integrity planning. Payers who continually refined their DRG review process, find themselves ahead of the curve in accuracy and fairness of healthcare costs.

Throughout its history, DRG auditing has evolved from a basic manual review process to a complex and technologically sophisticated system integral to the healthcare payment landscape. The goal has always been to ensure hospitals are paid accurately for the care they provide, preventing both underpayment and overpayment, and avoiding the potential for fraud and abuse in the system.

This article explores the evolving role of DRG audits within the ecosystem of payment integrity. We dissect the industry drivers, the restraints and challenges faced, and the opportunities we see as we progress through 2024.

Let's partner to a clear path to greater accuracy and cost savings.

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