Revenue Integrity Audit – Opportunity Assessment Framework
Compliance-Driven Revenue Capture and Continuous Improvement; maximize revenue opportunities and validate DRG compliance with a Provident DRG Audit.
DRG Audit Overview
Constant regulatory changes pertaining to compliant billing and coding have healthcare practitioners and facilities alike facing decreasing reimbursement and escalating costs. Optimizing reimbursement is a challenging task with private and governmental insurance providers continuing to cut costs and deny payment for services through the implementation and use of audit tools and processes (such as the use of Recovery Audit Contractor (RAC) Audits by governmental payers). As payers continue to take proactive measures to decrease billing and reimbursement deficiencies, physicians and healthcare practices need to be aware of the changes and the potential risks involved in improper billing which may include loss of revenue, financial sanction, fraud investigations, and exclusion from participation in government programs.
Access to appropriate resources and technical expertise are essential in generating the increased revenue necessary for a healthcare institution’s survival. Provident Management Consulting’s billing and coding professionals have developed tools and techniques designed to identify reimbursement opportunities. Our customized DRG Audit processes allow us to effectively identify problem areas and provide our clients with workable solutions.
A COMPREHENSIVE APPROACH
Using Provident’s proprietary DRG audit methodology, Provident clinical reviewers will identify and review the accuracy of the data used to assign the current DRG and deliver meaningful reports that highlight areas for improvement and educational opportunities.Our recommendations incorporate industry standards and best practices for clinical documentation.The Provident team also summarizes potential cases for rebill, streamlining the time-intensive rebill process. The DRG audit methodology focuses on the following data elements:
- DRG assignment
- Principal diagnosis and procedures
- MCCs and CCs, as necessary
- POA indicators, as necessary
- OR procedures, as necessary
- SOI level (APR-DRG review specific)
- Discharge disposition
- Secondary diagnoses and procedures, as necessary
- Query recommendations, as necessary
Depending on our client’s need we will determine the best structure of MS-DRG and APR-DRG audits including:
- Length of review, including continuous and/or one-time audit frequencies
- Retrospective or pre-bill
- Approach to sample selection and size (targeted based on known areas of weakness or random)
- Payers (targeted, all-inclusive or federal programs only)
Provident clients can also expect a robust summary of findings including:
- Number of charts reviewed
- Number of recommended changes
- Average impact per record changed and per record reviewed
- Value of charts reviewed
- Changes in reimbursement
- Number and impact of records with DRG changes and attributing factor(s)
- Query opportunities
- Education opportunities (as applicable)
- Trending (as applicable)
Provident’s Revenue Integrity Audit clients typically achieve:
- 10 – 15% shifts in the DRG
- Benefit per chart reviewed: $500+
- Value per chart with recommended change: $2,000-$4,000
- ROI: $4-$5 prebill/rebill opportunity per $1 of Audit Cost
- Weekly AHIMA approved CE credits
Provident works with our clients to identify timelines, deliverables and educational opportunities that work best for them. Our continuous improvement and DRG audit methodologies are tailored to meet the unique needs of each client, while achieving the necessary balance between risk, compliance and performance.
WHAT SETS US APART
- Audit findings result in actionable role-specific training, delivered directly to the staff’s inbox. Targeted training of coders, providers, case managers and clinical documentation specialists ensures continuous process improvement.
- Proven methodology identifies, tracks and reduces audit issues and drives towards clinical documentation and coding excellence.
- Proven track record of creating value and improving compliance for healthcare organizations across the country
Provident has a national team of dedicated professionals experienced in providing revenue integrity audit services including assessments, improvement initiatives and training. Provident’s team has helped clients improve DRG assignment accuracy and has provided continuing education to coding, clinical documentation improvement (CDI) staff and providers. Our professionals maintain nationally recognized coding and compliance certifications and credentials including RHIT, CCS, AHIMA approved ICD/CM PCS trainer, JD, CFE and others.