DRG Claims Management is happy to attend the Florida Association for Healthplans (FAHP) conference and participating in "Giving Back to our Communities - Kids Snack Bag Packing Station." Thanks to MTM for sponsoring and allowing us all to join a great cause! #FAHP
DRG CLAIMS MANAGEMENT
Hospitals and Health Care
Upper Saddle River, New Jersey 689 followers
Do you want to increase your profitability by at least 30% annually at your health plan? we can save you $3-$6 MILLION!
About us
DRG Claims Management provides an unprecedented, customized pre-payment DRG claims review services for any DRG claims payer, especially Medicare Advantage and Medicaid Managed Care plans as well as other commercial payers. We provide our services to dozens of payers on a national level and have experience with providers in all 50 states and Puerto Rico. Our expertise and proven results are achieved consistently across all DRG methodologies inclusive of APR-DRG, MS-DRG, AP DRG and all federal, commercial, and state specific pricing schedules. We’ve designed state-of-the-art workflow applications and developed a proprietary algorithm-based auditing process screen and identify claims with the highest potential for recovery results. We review medical record documentation for the accuracy of the assigned DRG and payment based on correct application of regulatory mandates and official guidelines and conventions. - all at no financial risk to our clients. • Our team is highly specialized in the intricacies of DRG methodology and coding and we find coding errors and overpayments of up to 60% of a claim’s original billed amount. The majority of overpayments are found in the mid-range of claims priced from $10,000 to $80,000. • Unlike the majority of our competitors, we preserve important provider relationships and maintain the professional dialogue until we obtain a signed provider confirmation of the DRG revision. • Provider “sign-offs” effectively eliminate costly appeals and overturning of the audit determination, thereby relieving the health plan of addressing resolution in a formal and resource-consuming appeal process. • On average, we achieve a yearly savings of $3-6 million of verified over-payments for every 100,000 members in a typical DRG payment environment, relative to the Plan’s demographics and membership case mix. Savings for Managed Medicaid/Family/Children’s plans is the range of $3M per 100k members.
- Website
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https://www.drgclaims.com
External link for DRG CLAIMS MANAGEMENT
- Industry
- Hospitals and Health Care
- Company size
- 11-50 employees
- Headquarters
- Upper Saddle River, New Jersey
- Type
- Privately Held
- Founded
- 2009
- Specialties
- DRG, medicaid, medicareadvantage, medicare, healthplan, healthplans, claimsmanagement, claims, healthcareprofessionals, healthleaders, healthcarefinance, healthinsurance, healthcare, healthcareinnovation, healthcare2019, healthcaresystem, healthcaretechnology, healthcarecosts, riskmanagement, and managedcare
Products
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DRG Claims Management
Claims Management Software
Ensuring compliance and integrity with provider-verified audit results.
Locations
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Primary
Get directions
Upper Saddle River, New Jersey 07458, US
Employees at DRG CLAIMS MANAGEMENT
Updates
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Honoring those who served and sacrificed. Thank you to all the veterans for your courage, commitment, and service. #VeteransDay #Gratitude #HonoringHeroes
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DRG CLAIMS MANAGEMENT reposted this
Welcome new MCRA Member, DRG Claims Management DRG CLAIMS MANAGEMENT has been offering cost containment solutions to health plans across the United States since 2013. Their services include post-payment model focused on addressing inaccurate coding and clinical errors retrospectively, maintaining good relationships with providers, and ensuring a smooth refund request process. Read more 👉 https://loom.ly/0kD2qps #DRGClaimsManagement #mcra #managedcarealliance
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See you soon!!! Healthcare Payment & Revenue Integrity Series (HPRI)
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Overcoming Barriers to Implementing DRG Audit Programs: Poll Insights Our latest LinkedIn poll uncovered the main challenges payers face when implementing DRG (Diagnosis-Related Group) audit programs. Here’s what we found: Poll Highlights: Provider's Hospital Conflicts - 75% Lack of Internal Expertise - 0% Provider Abrasion Concerns - 25% Regulatory Compliance Issues - 0% Key Takeaways: Provider's Hospital Conflicts (75%): Most respondents pointed to conflicts with providers as the top barrier. This isn’t surprising, as hospitals often fear audits may lead to revenue loss. Payers should focus on building transparent, collaborative relationships to mitigate these concerns. Consider a “What if” analysis—audit records received for utilization review or quality controls. While overpayments may not be pursued, identifying patterns could justify renegotiations. Lack of Internal Expertise (0%): No respondents saw this as a barrier, suggesting confidence in internal capabilities or reliance on external partners. Continuous education remains key to keeping up with regulatory changes. Provider Abrasion Concerns (25%): Audits can strain provider-payer relationships. Framing audits as opportunities for improvement, rather than fault-finding, can help reduce abrasion. Emphasize education and support to foster collaboration. Regulatory Compliance Issues (0%): Surprisingly, this didn’t register as a concern. However, with the complexity of healthcare regulations, payers must stay proactive in compliance efforts. Conclusion: The poll underscores the need for clear communication and collaboration to overcome these barriers. By addressing these challenges, payers can create effective audit programs that ensure compliance and foster positive provider relationships. Join the Conversation: Share your experiences and strategies in the comments to help us all navigate these challenges together.
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We will see you in Las Vegas for HPRI West. Please stop by our booth! https://lnkd.in/eTUGFV5h
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Join us August 18 - 21 in New Orleans for NAMPI 2024! https://nampi.net/ We will be in Booth 10, but look for our banner - we look forward to seeing you there!
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https://nampi.net
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DRG CLAIMS MANAGEMENT reposted this
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DRG CLAIMS MANAGEMENT reposted this
Evaluating the Effectiveness of Skilled Nursing Facility (SNF) Claim Audit Processes In our recent poll, we asked our network to rate the effectiveness of their current SNF claim audit processes. The results were intriguing: Poll Results: 1) Highly effective: 100% 2) Moderately effective: 0% 3) Slightly effective: 0% 4) What SNF audit process? 0% Understanding the Results: Highly Effective (100%) The unanimous vote for "Highly effective" suggests confidence in current audit processes, likely due to: 1) Comprehensive Audit Protocols: Well-defined protocols covering critical aspects of SNF claims. 2) Skilled Auditors: Experienced auditors knowledgeable about SNF regulations. 3) Use of Technology: Advanced audit software and data analytics enhance accuracy and efficiency. 4) Continuous Improvement: Regularly reviewing and refining audit processes to adapt to changes. Moderately Effective (0%) and Slightly Effective (0%) No respondents rated their processes as moderately or slightly effective, indicating possible non-participation of those with less effective processes or a small sample size. What SNF Audit Process? (0%) All respondents have some form of SNF claim audit process, highlighting the industry's recognition of the importance of auditing. Key Takeaways: 1) Importance of Effective Audits: Essential for compliance, financial health, and quality improvement. 2) Need for Skilled Professionals: Expertise in SNF regulations and auditing techniques is crucial. 3) Role of Technology: Enhances efficiency and accuracy of audits. 4) Moving Forward: Organizations looking to improve their SNF claim audit processes should: 5) Invest in Training: Ensure the audit team is well-trained and up-to-date with regulations. 6) Adopt Advanced Tools: Utilize audit software and data analytics. Regular Review: Continuously assess and refine audit protocols. By focusing on these areas, organizations can enhance the effectiveness of their SNF claim audit processes, leading to better compliance and financial performance.
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Evaluating the Effectiveness of Skilled Nursing Facility (SNF) Claim Audit Processes In our recent poll, we asked our network to rate the effectiveness of their current SNF claim audit processes. The results were intriguing: Poll Results: 1) Highly effective: 100% 2) Moderately effective: 0% 3) Slightly effective: 0% 4) What SNF audit process? 0% Understanding the Results: Highly Effective (100%) The unanimous vote for "Highly effective" suggests confidence in current audit processes, likely due to: 1) Comprehensive Audit Protocols: Well-defined protocols covering critical aspects of SNF claims. 2) Skilled Auditors: Experienced auditors knowledgeable about SNF regulations. 3) Use of Technology: Advanced audit software and data analytics enhance accuracy and efficiency. 4) Continuous Improvement: Regularly reviewing and refining audit processes to adapt to changes. Moderately Effective (0%) and Slightly Effective (0%) No respondents rated their processes as moderately or slightly effective, indicating possible non-participation of those with less effective processes or a small sample size. What SNF Audit Process? (0%) All respondents have some form of SNF claim audit process, highlighting the industry's recognition of the importance of auditing. Key Takeaways: 1) Importance of Effective Audits: Essential for compliance, financial health, and quality improvement. 2) Need for Skilled Professionals: Expertise in SNF regulations and auditing techniques is crucial. 3) Role of Technology: Enhances efficiency and accuracy of audits. 4) Moving Forward: Organizations looking to improve their SNF claim audit processes should: 5) Invest in Training: Ensure the audit team is well-trained and up-to-date with regulations. 6) Adopt Advanced Tools: Utilize audit software and data analytics. Regular Review: Continuously assess and refine audit protocols. By focusing on these areas, organizations can enhance the effectiveness of their SNF claim audit processes, leading to better compliance and financial performance.
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