Hospital billing validation is based on DRG (diagnosis-related group) system, that classifies hospital cases into groups that are clinically similar and are expected to use similar amounts of hospital resources. This classification was developed as a collaborative project by Robert B Fetter, PhD, of the Yale School of Management, and John D. Thompson, MPH, of the Yale School of Public Health (1). The system is also referred to as “the DRGs”. When used for payment, the amount per episode of care is fixed for patients within a single DRG category (based on average cost), regardless of the actual cost of care for that individual episode, but varies across DRGs.
In general, DRG payments are used for inpatient care services, but are also frequently used for day care and surgery services. Depending on the country, a number of exclusions may also apply, such as for expensive drugs and medical devices, high-tech interventions, transplantations, emergency care, psychiatry, rehabilitation and long-term nursing care (2).
Healthcare providers are paid by insurance or government payers through reimbursements based on the DRG coding.
We support healthcare providers, insurance companies and government payers of the European Union with:
- up-to-date expertise on strategic and operational aspects of medical controlling including
- DRG validation as an independent detailed comparative analysis of DRG-based hospital billing
- in addition, all cases will be comprehensively examined for medical plausibility.