Published On: Mon, Apr 20th, 2020

Ensure Clean Claims Before a DRG Auditor Arrives

During the 1980s Diagnosis-Related Groups were created to categorize patients by similar costs and clinical characteristics. This system was soon adopted by the Centers for Medicare and Medicaid Services to help control medical costs and auditors were sent to check the numbers. Private insurance companies are also employing Recovery Audit Contractors to recover revenue, which can put your hospital under greater scrutiny and cause DRGs to be denied or lowered. To protect your system before an auditor arrives, do your own audit, have good medical coders and understand the system.

Understand the DRG System

Do Your Own Audit

With the help of software solutions, you can conduct your own DRG auditor training in-house and stay on top of your coding and billing. Some of these solutions will continuously run in the background and go over each Diagnosis-Related Group as it is entered in the system to flag outliers and make the job of your in-house auditing team easier. When a CMS or RAC auditor disputes a claim or audits your system, the records from your internal audits can be submitted to save time.

Find and Retain the Best Medical Coders

Hiring experienced medical coders can be a challenge because there are many organizations to compete with. The best medical coders can glean information from charts based on a knowledge of diagnoses, medical treatments and the coding systems. This can be trained to recent graduates if you have developed a robust training system and the time.

To retain the coders you have, use positive learning experiences instead of negative rebukes for mistakes, offer continuing education and have state-of-the-art technology. Flexibility in scheduling, including the option to work from home, can be a big incentive for coders to stay with cloud-based data storage and software solutions can making medical coding from home easy and secure.

Understand the DRG System

When you understand how the DRG system works, you can find the flaws in your system more easily and fix them before they become huge problems. This means knowing that Medical Severity DRGs are those most often used and are determined by the principal diagnosis and procedure, certain secondary diagnoses the CMS identifies as comorbidities and complications, as well as major comorbidities and complications. This can help you best define which codes to use for each patient and establish procedures for your staff.

The best way to reduce the amount of lowered DRGs and denied claims, is to audit the systems yourself on a regular basis. This means having the team and software necessary for tracking your DRGs as well as ongoing training and education for everyone involved to be aware of how the system works.