DRG Claims Management provides an innovative approach to DRG claims validation and recovery of confirmed over-payments on behalf of the segment of payors that pay claims based on DRG methodology: Medicare Advantage, Managed Medicaid, commercial plans, IPAs, TPAs, ASO/MSOs, Managed Long Term Care Programs (MLTC), and PACE programs, Additional wrap around services are also offered, including:
- Identification of cases requiring medical necessity and re-admission reviews
- Hospice services recoupment for Medicare Advantage plans
- Cost outlier reviews: DRG coding analysis and medical necessity validation of length of stay / level of care of each billed day with the goal of reducing or eliminating the outlier surcharge
- Third party “tie breaker” reviews for unresolved DRG claim disputes