How does a medical claim audit work?
Our Services: Medical claim audit 1

Audit of medical claim identifies hospital error in reported/billed medical professional services.

Medical claim audit for the EU

Optimise hospital billing or reimbursements with
1) independent DRG validation

DRG validation procedures are necessary to confirm that all patient information encoded by a hospital and reported to its claim is plausible and consistent with both:

  • with the records of the attending physician and
  • information contained in the medical record.

It is always important to have different options when implementing DRG validation, as you can use either internal coding personnel or an external provider. If your organisation of sources encoding/DRG validation, ensure that your provider has an internal method for verifying the encoding quality. And if you use internal personnel to implement it, it is helpful to use independent DRG validation at regular intervals.

Effective DRG validation also includes continuous tracking and measuring results to avoid future coding errors. A significant part of this process requires close attention to electronic medical records. In addition, you should evaluate any system issues in your organisation that can affect data flow from registration to coding and billing procedures.

Our experts have many years of experience in the evaluation of DRG-based remuneration for both service providers and payers (insurance companies and state institutions).

 

MedcoDRG DRG-related Services_2

2) Medical controlling of European cross-border DRG payments

DRG systems in Europe are very heterogeneous, mainly due to different classification variables and algorithms and cost accounting methods. However, because of the challenge of increasing patient mobility within Europe, health systems are forced to use a common language for patient classification to compare and identify similar patients, e.g. for reimbursement purposes (3).

Although the main reason for the decision to include DRG in the compensation mix varies from health system to health system, there are similarities. The transition to DRG seems to have been induced mainly by the need to increase efficiency and sustainability.  In particular, to overcome escalating healthcare costs, inefficient and often large hospital networks, adverse consequences of the pre-introduction of DRGs (such as long average residence time, low admission rates, excessive delivery of services) and scepticism as to whether the care provided was adequate. In some contexts, DRG was also seen as a means of increasing the transparency of hospital performance and remuneration (4).

We carry out DRG validation for cross-border hospital payments in European countries.

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