Plan Client Success – CAVO Pre-pay DRG reviews at Regional Payer

Nov 24, 2020

Regional Health Plan’s Pre-Pay DRG Review Team Uses CAVO to Increase Productivity by 200%


RNs performed DRG validation reviews primarily from providers’ EMRs. Reviews were a page-to-page comparison (often averaging 500+ pages per case) within slow systems with cumbersome navigation. Once RNs located decision information, they created screenshots and saved them to an internal shared drive. After using these EMR screen shots to determine whether to downgrade each DRG, reviewers opened a letter template in Microsoft Word, populated it with the case’s relevant feedback, and emailed it directly to the provider. The final step was updating their workflow system. After navigating one of multiple EMRs plus accessing a shared drive, Microsoft Word, and email, the final step was updating their workflow system. CAVOs pre-pay DRG reviews functionality can change all of that.


Instead of reviewing directly within the EMR, nurse reviewers easily export a PDF of the medical record and load it into CAVO®, transforming it into searchable, actionable data. RNs quickly locate needed review information with search functionality and use tags to categorize specific pages for future reference. The team creates provider letters leveraging organizational templates pre-loaded in CAVO during implementation, leverages CAVO’s pre-pay DRG reviews functionality—enabling quick inclusion of specific information and/or pages supporting the review decision, and emails directly to the provider from within CAVO.


RNs complete reviews within a single platform, following one consistent team process.  With the ability to search medical records using words, phrases, and pre-defined searches—plus tag decision documentation with a couple of mouse clicks versus creating and saving individual screenshots, overall DRG review team productivity has increased by approximately 200% within their first 90 days since CAVO onboarding. Plus, providers are now receiving specific medical record information that supports the determination. This new process has been well received and should begin to reduce future provider appeals.

Productivity has increased 200% within the first 90 days since CAVO onboarding.