Health Plan Challenges in the DRG Claims Review Process

Feb 19, 2021

Combating Common Health Plan Challenges

If you’re an executive at a health plan, you likely spend a fair amount of time and energy thinking about minimizing provider abrasion, but what about the health plan challenges you face on the payer side of the equation?

Health plans have long struggled with inefficiencies that compromise provider relationships and hinder business performance. To illustrate those inefficiencies, let’s consider what the DRG review process (likely) looks like for you today … and what it could look like for you tomorrow.

Today’s Payment Integrity DRG Claims Review Process

If you’re like most health plans, retrieving the documentation for DRG reviews is a manual process, perhaps one you outsource to a record retrieval vendor. But regardless of how you make requests and receive medical records—whether that’s via snail mail, email, fax or portal—record retrieval is a time-consuming, labor-intensive process that places significant demands on you and your providers.

Unfortunately, the inefficiencies don’t end with the release of information process. Most of the medical records you receive are unwieldy, both in size and scope. The average hospital record is 250-300 pages, and it’s extraordinarily inefficient for coders to manually flip through hundreds of pages to pinpoint:

  • the decision data that tells you whether the right DRGs were coded, and
  • whether you have the right documentation for each DRG.

Finally, once the DRG validation team has determined whether it’s a clean claim meeting your plan policy or requires a partial or full denial, the decision must be communicated to your provider. Most likely they are writing a letter using a word processing software, manually populating it with relevant feedback, and sending the information via email or workflow tool – which then also requires updating if not automated based on preceding steps. Through it all, your team typically has to move in and out of multiple systems with varied interfaces and required step, further impeding productivity.

That’s a total of four significant DRG validation health plan challenges that have been a drag on health plans (and providers) for quite some time.

Tomorrow’s Payment Integrity DRG Claims Review Process

Now consider an alternate reality in which you utilize CAVO®, a technology solution created by TREND Health Partners, to streamline this process. CAVO is an that allows you to use a single platform—with a user-friendly interface purpose-built for payment integrity claims review processes—to complete DRG reviews and decrease these common health plan challenges.

Instead of the scenario described above for record retrieval, with CAVO Connect®, your providers simply download our app to enable direct EMR access. Then, through open API, you are able to call on the medical records you need, for access within your workflow tool – or present that data in CAVO in a format ready for reviews to begin. The process eliminates all the burden of record retrieval on the part of your providers and places minimal burden on your own DRG review staff, saving time and putting an end to the administrative excess associated with the record retrieval process.

Alternatively, your plan can continue its current record retrieval processes and choose for CAVO to intake, aggregate, and extract data from your records. Either way, once you have medical records in hand (so to speak), your coders can use CAVO to perform complex searches of the PDF of the medical record, much like you use Google or your favorite search engine. Plus, your DRG validation has the option to leverage our library of 100s of pre-defined searches – complex queries using “and”, “or”, and “not” statements designed to quickly locate claims decision information.

Using CAVO’s search functionality, results are instantly displayed in order of relevance. Coders are also able to efficiently click through to the relevant portion of the record and use tags to categorize pages for future reference. The team also has the ability to set up pre-defined searches, which can be customized to your plan during implementation.

With the CAVO and TruCode Essentials Encoder integration, coders can easily assign and validate the appropriate codes backed up by TruCode’s and CAVO’s comprehensive references – seamlessly from within the CAVO technology, eliminating one of the typical system switches during a DRG validation.

Finally, coders can use CAVO’s highlight and annotation tools to pinpoint escalation and/or determination information for streamlined communication and clarity regarding decisions. The technology’s “letter” functionality provides templates – customizable to your organization – that enable efficient attachment of relevant information and/or pages supporting the review decision.

CAVO Increases Payment Integrity DRG Review Productivity by 300%+

With all the benefits added together, it’s probably not hard to envision how CAVO increases payment integrity productivity 300 to 500% using a single platform custom-built to streamline reviews. And CAVO Connect offers the accrual of even more benefits via automation of the record retrieval process. Think about how reducing the burden associated with record retrieval and manual record review also improves the productivity of your team. By saving them the endless hours they are spending looking for specific information while reviewing claims, your current staff can handle many more reviews per day – adding productivity without more staff. Moreover, if you are having difficulty finding enough qualified coders—or don’t have the budget to hire enough people—you have solved that problem as well.