eValuator Corrects 22% of External Vendor-Coded DRGs, Resulting in $1M Financial Impact Over 90-Days

topics:

auditing

,

drg

,

pre-bill

Posted On :

OVERVIEW

Facing challenges in hiring inpatient coding staff, the client turned to outsourced coding support. eValuator identified a high DRG change rate associated with the outsourced vendor, resulting in the capture of approximately $600,000 in revenue and averting potential overbilling of over $400,000 in the same quarter of the outsourced vendor’s implementation.

CHALLENGES

  • The ongoing struggle to fully staff the inpatient coding function resulted in a reliance on outsourced coding support.
  • Outsourced agency provided no visibility into the efficacy of coding.
  • Initiation of outsourced coding support coincided with eValuator’s reporting of a significantly increased DRG change rate or a decline in coding quality.

GOALS

  • Maintain a quarterly baseline DRG change rate of 12% while utilizing outsourced coding support.
  • Mitigate any adverse effects of subpar coding from the outsourced vendor before billing.
  • Leverage eValuator-driven results to support the recruitment of permanent coding staff and additional audit assistance.

OUTCOMES

  • The client experienced an approximate 70% increase in their DRG change rate in a single quarter, climbing from 13% in Q3 to 22% in Q4. This spike coincided with the quarter when the client implemented outsourced coding support.
  • The elevated DRG change rate in Q4 led to the capture of approximately $600,000 revenue for that quarter, revenue that would have otherwise been lost. Furthermore, within the same quarter, eValuator averted potential overbilling and mitigated risks totaling over $400,000.
  • The significant increase prompted a reevaluation of the outsourced coding support. The assessment revealed that the outsourced coder was the main contributor to coding errors, prompting a change in contract coder.