Solutions for Common Pain Points in the Pre-Pay DRG Review Process

Sep 20, 2021

Introduced in the 1980s, a DRG  is a crucial component of today’s healthcare system. Most DRGs today are reviewed in a post-pay environment – providing challenges for both provider and payer alike.

For the provider, the post-pay DRG review comes with considerable abrasion, often requiring service fees already collected to be returned to the payer after a claims review that sometimes comes a year after the payout has occurred. The post-pay environment also leaves the payer in a “pay and chase” mode, as they review DRG claims they’ve already paid but then must “chase down” the supporting medical record, validate the documentation, and then determine appropriate reimbursement for errors found. The pre-pay DRG Review Process environment is slow and costly, requiring considerable financial and human resources.

Fortunately, there’s a new day dawning in the DRG review process that brings DRG into a pre-pay environment, providing an opportunity to create a streamlined process that diminishes administrative burden while lowering costs and saving time.

Where there’s a problem, there’s the opportunity for a solution. Here are some of the common pain points that prevent moving to pre-pay DRG review process.

1. Claim Selection

There are numerous considerations to take when selecting which DRG claims to review. While internal historical savings and payment thresholds determine most review selections, there are other reference points to consider in making the determination. By looking for provider trends in the data for outliers, a consistent process can be developed to move the DRG review into pre-pay. With awareness of historical, problematic codes, and length of service (LOS) trends, plans can capitalize on savings opportunities, even while decreasing provider abrasion and drastically reducing review fatigue.

2. Record Exchange Challenge

DRG requests, faxes, emails, online portals, U.S. mail – all the things that make the DRG review process slow and inefficient. Before the DRG claim is ever reviewed, the time required to exchange the record between payer and provider typically causes enough delay to keep the claim from being resolved in pre-pay. From slow delivery times via U.S. mail to file size limitations via fax and online portals, the record exchange has long been stuck in antiquated delivery methods. Technology has taken the lead in being able to exchange DRG records instantly.

3. The Review Process

The third pain point of moving DRG into pre-pay is the actual review itself. After selecting the suspect DRG claim and exchanging the record, it’s now time to review it. Here are some of the challenges associated with the review process:

    • Review fatigue
    • Insufficient technology support
    • Complicated internal policies
    • Multiple diagnosis complexities
    • Large, cumbersome PDF files

Each of these elements hinders the accuracy of findings and savings opportunities in the review process and make it extremely difficult to manage DRG review in pre-pay. But like the above common pain points to moving DRG into pre-pay.

There’s A Solution For That – Pre-Pay DRG Review Process

Sometimes humans won’t change something until the pain is bad enough. That’s no different in our systems and processes in business, and that’s certainly true within the healthcare ecosystem. Sometimes we get used to the pain points and live with them, either because it’s the only way we know or because we don’t know that there are better options out there. There truly is a better way to the DRG review process, and maybe it’s time you take a look!

About CAVO

At TREND Health Partners, we pride ourselves on revolutionizing the claims review process by applying cutting-edge technology solutions to the request and delivery of medical record information between health plans and providers. CAVO® technology enables health plan reviewers to access medical records, itemized bills, and additional clinical data with ease.

With over one million completed case reviews, CAVO delivers technology proven to scale up your medical record reviews and increase your team’s productivity by over 400%.