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Switching from an outdated manual coding audit program to tech-enabled pre-bill eValuator™ increased the average DRG change rate from 10% to 18%, boosted auditor productivity and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