OVERVIEW

Switching from an outdated manual coding audit program to tech-enabled pre-bill eValuator™ increased the average DRG change rate from 10% to 18%, boosted auditor productivity and identified coder education for improved accuracy.

CHALLENGES

• Manual audit process with use of spreadsheets and random case selection.
• Lacked visibility into audit program contributions (financial impact, productivity metrics, & quality improvements).
• Program did not include outpatient encounters.
• External audit firm failed to meet expected ROI.

GOALS

• Automate case selection to prioritize high value encounters (financial and quality aspects) for both inpatient and outpatient claims.
• Implement automation for the auditor & coder rebuttal process, eliminating the use of spreadsheets.
• Enhance the ease and depth of reporting.
• Achieve the organization’s ROI goals by enhancing financial outcomes for the enterprise.

OUTCOMES

• eValuator™-flagged encounters increased the DRG change rate from 10% to 18%.
• Auditors, concentrating solely on eValuator™-flagged encounters, achieved an average net new reimbursement of $660 per DRG change.
• Identified additional coder education opportunities for improving overall coding accuracy rates.