eValuator Uncovering Needles in the Haystack

Coding integrity audits today generally share one characteristic in common: the reviewed claims make up only a small percentage of those billed. But, if you are only reviewing a portion of your billed claims, what “golden needles” might you be missing in the haystack of claims?

Health systems frequently rely on external vendors and/or limited internal staff to audit their claims on a post-bill basis. However, as it becomes standard practice for these vendors to focus only on specific DRGs, they often overlook the critical “golden needles“, cases that can have the significant financial impact. These “golden needle” cases usually exhibit three similar characteristics:

Limiting audits to a portion of claims yields incomplete and unreliable insights into reimbursement impact, quality scores, payment delays, and denials. Furthermore, this limited scope overlooks crucial conditions and procedures within the patient population, resulting in revenue leakage and an inadequate feedback loop for coding professionals. This shortfall can adversely affect a provider’s net revenue retention rates and increase their cost to collect.

Analyzing 100% of your claims before the bill is issued is the holy grail for catching and correcting revenue & coding integrity issues proactively. However, manually analyzing all cases demands a level of staffing and time commitment that is not feasible for providers.

eValuator, a pre-bill revenue integrity solution, addresses this challenge with its automated workflows and robust reporting tools. It analyzes 100% of inpatient, outpatient, and pro-fee  claims, flagging those with potential revenue and coding integrity issues before billing. eValuator enhances staff efficiency and optimizes financial outcomes by flagging claims with the most significant financial impact and those likely to change, including those “golden needles” that occur infrequently and often result in coding and sequencing errors.

Identifying those rare “golden needle” claims, whether through internal audits or with external vendor assistance, is streamlined with eValuator. In a month’s sample, eValuator flagged claims that resulted in DRG changes, carrying significant financial impact such as:

Identifying these “golden needles” also yields significant downstream benefits. For instance, one of our eValuator clients saved over $500,000 in contingency payments to their post-billing DRG validation vendor in their first year of utilizing eValuator for internal pre-bill reviews, achieved without additional staffing.

Another client noted that eValuator provides comprehensive insights into flagged claims, offering a complete narrative behind each review, encompassing not only the financial impact but also the precise reasons for flagging—an advantage absent in their previous technology, which merely recommended an audit plan based on past quarter findings for already billed claims. This client also contrasted their former tool’s limited and generic algorithms, which prolonged the auditing process.

If your organization relies on post-bill randomized audits covering only a fraction of your claims, your organization might be exposed to significant revenue leakage. Visit StreamlineHealth.net to request more information and see how eValuator can help you find the golden needles in your unique revenue cycle landscape and ultimately get paid for all the care that you provide.