DRG Bill Audits

ACCURATE provides detailed hospital bill audits of DRGs, employing experienced certified medical coding specialists, nurses and physicians, with extensive knowledge of coding systems and coding compliance guidelines, to ensure compliance and identify possible errors in coding that might lead to over payments.

Our software checks diagnosis and procedure codes and links these to validation rules that are based on various code sets, to identify potential errors in the hospital claims data. Our professional auditor team works closely with clients and delivers reports concerning potential audit problems and result information on a regular basis. Our long-term experience with DRG systems permits us to conduct DRG audits efficiently and on a high level while keeping costs low.

ACCURATE reviews all paid claims data based on specific criteria to identify claims of interest that contain:

  • One day lengths of stay with specific diagnoses
  • Lengths of stay inconsistent with severity of assigned DRG
  • Assigned DRGs inconsistent with the type of services received
  • DRG assignments with a cc or MCC; these are reviewed for possible error in diagnosis assignment

In addition to these criteria, ACCURATE analysts run “what if” payment scenarios with claim data to determine possible alternative DRG assignments.

For claims that ACCURTE finds lacking in documentation to support the submitted DRG, or that are found to have received inappropriate inpatient admission status, ACCURATE contacts the hospital to discuss DRG change or inpatient status change. The results of these negotiations enable us to further conduct substantiated audits.

When this process results in a DRG re-assignment, ACCURATE will send a DRG Rationale Report to hospital representatives indicating that all parties agree with the DRG change.