Moving DRG Into The Prepay Process: Record Exchange Challenge

Aug 30, 2021

So you’ve selected the DRGs that you want to review…now what? Next in the process is the record exchange. One of the biggest hurdles to moving DRG reviews into the prepay process is the actual record exchange between payer and provider. Traditionally, all too often, the amount of time required to execute the record exchange moves the review time outside of the shorter review window required to meet the prepay deadlines. This antiquated process is what keeps the vast majority of DRGs being reviewed post-pay.

Dinosaurs Still Exist?

Well, figuratively speaking, yes! The vast majority of record exchange still occurs via fax, mail, and online portals in the medical world. In a 2018 report by, 71% of hospitals surveyed said they continued to use mail or fax for sending and receiving summary of care records in 2018. This is a stunning statistic in a modern world of technology and automation, revealing the amount of time, money, and personnel consumed just through the record exchange process alone.

One If By Fax, Two If By Mail

Let’s consider the idea of sharing a Sepsis medical record. These records can be hundreds of pages long. While a fax machine may seem like the most efficient way to share these records, they are also hampered by file-size limitations. If a fax machine is limited to sharing a file size of 200 pages, but the record is 350 pages, the only alternative in this Stone Age record sharing process is to mail it. Now we’ve moved from dinosaurs to the Pony Express, and admittedly, the result isn’t any better.

Mail takes days to deliver, eating away at the shorter time window allowed to meet the prepay review requirements. Additionally, there’s an extra cost to consider in mailing, such as the time required to box the records and the extensive shipping costs. To put it succinctly: mailing medical records is slow and costly.

But wait, there’s more! Once the payer receives the records, the record must be linked to the request, which takes additional time. There are also times a provider will send a record to a payer without a request because the payment threshold is in the automatic review range. These “orphan records” arrive at the payer with no current request record to match, so it takes additional time to link the record to review. Finally, upon arrival, the payer must verify that the records received are complete. When a record is not complete, another request must be made for the record, and the process begins again. This redundancy in requests and the time required for exchange prevents the DRG review from happening in pre-pay.

Even the trend of utilizing online portals to share important DRG records is time and cost-prohibitive. Some portals have file-size limitations, forcing the mailing of requested records. Additionally, even though the exchange is executed digitally, it still requires a team of people to make the exchange happen:

  • The payer requests a record to review.
  • The provider searches for the record, and then has to upload it into the portal.
  • The payer receives the record in an image format, and must verify the completeness of the record.
  • The determination is then returned to the provider for reimbursement adjustments.

Every one of these methods, whether fax, mail, or portal, requires human effort and systems that cause a delay in the process that prevents the possibility of reviewing DRGs in prepay.

Pass The Band-Aids

This manual process of record exchange is a painfully laborious transaction that happens millions of times per day. It is a significant cause of administrative burden for both payer and provider and one of the number one causes of provider abrasion. The healthcare system has been bleeding financially, so to speak, with significant waste attributed to billing and insurance-related costs to the tune of $496 billion a year. According to a report by Center for American Progress, the administrative excess sits around $248 billion annually. Utilizing fax, mail, and online portals have essentially served as band-aids over a gaping hole in the healthcare system, driving up cost and consuming important resources across the entire ecosystem.

Enter Technology

Here’s where the DRG review game shifts: technology. Imagine a scenario where a plan can request a record for review from a provider and receive that record immediately. With CAVO® Connect, the record exchange happens instantly and automatically links the record to the request while verifying the completeness of the record received. This instant, automated solution saves days and even weeks in the exchange process, allowing for the review to be completed in prepay.

However, even if a provider uses fax, mail, an online portal, or the growing world of APIs for the record exchange, we have a best-in-class solution that takes the image of the record and extracts the data, putting it into a usable and searchable format. By utilizing a Google-like search function, our CAVO® DRG Predict platform pulls pertinent data for review and does it in a fraction of the time it takes for a nurse or coder to review manually. This powerful productivity lift allows a DRG review to be completed in minutes and turns possibility into reality of moving DRG reviews to prepay.

Additionally, our CAVO DRG Predict solution recognizes common coding errors in DRGs, allowing a reviewer to search for those errors instantly. The efficiency of this solution eliminates the additional time required to review and increases accuracy in findings. For example, CAVO DRG Predict will extract clinical information like ventilator time, so the nurse or coder can immediately determine whether DRG 870 is supported.

The result of our end-to-end CAVO® platform, is that it produces at least a 5x productivity lift that eliminates much of the time required to review, allowing DRG reviews to legitimately move into prepay. It is the premier solution for assuring appropriate payouts and reimbursement, according to the payer-provider policy. It also saves time, money, and decreases administrative burden and provider abrasion.