OVERVIEW

Client transitioned from an inefficient, sporadic retrospective coding audit on spreadsheets to a pre-bill, real-time coding integrity program handling larger audits without extra staff.

CHALLENGES

• Ad-hoc retrospective auditing program with minimal outcomes.
• Rise in denials attributed to coding and DRG downgrading by payors led to a solely reactive approach.
• Coder quality feedback frequently delayed by months.
• Staffing challenges hindered the addition of positions.

GOALS

• Develop a technology-driven pre-bill audit to flag encounters with revenue integrity issues before billing.
• Decrease coding-related claim denials.

OUTCOMES

• Reduced coding related denials and DRG downgrades by 90%.
• Increased total volume of encounters audited pre-bill 300% with no additional staff.