Who Should Use This Service
Health plans that reimburse facility claims based on a DRG methodology (MS-DRG, APR-DRG) should utilize DRG Validation. DRG Validation can be effective if claims are paid at straight DRG price, percentage rate of DRG, a base-rate DRG payment or a lesser of percent of charges versus DRG rate.
Process for Evaluation of Client’s Claim
HealthMind will evaluate your facility claims for a six-month period of paid claims data to assess whether your company’s specific providers and coding errors are those in which we have had successful experience with our DRG Validation & Pricing program. In order to perform this evaluation the your company must be able to send HealthMind a reimbursement indicator specifying how the claim is paid relative to the claim types previously described or, alternately, a claim’s file containing only those claims subject to the program criteria. While this analysis cannot predict the precise savings since the audit will not actually be performed, the analysis does provide valuable insight as to whether your company is significantly overpaying and whether the audit program would produce meaningful savings.
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