Diagnosis-related Group (DRG) is a term for the classification system used to categorize patients, the severity of their ailments and the costs of treatment for each ailment. DRGs classifications require periodic auditing. Here are three facts about DRG audits.
1. Why They’re Necessary
DRG audits utilize the statistical data gathered from DRGs to help standardize the pricing of certain healthcare procedures and keep track of fluctuations in pricing over time. The goal is not to second guess the healthcare provider, but to ensure that all of the paperwork was processed correctly. If paperwork is processed incorrectly, billing issues will occur and statistical data may be thrown off. Some diagnosis and treatment types experience more errors than others, so DRG audits are particularly important to conduct in these areas. When the software catches errors, it can alert the auditor of the issue so he or she can review it.
2. What They Are
DRG audits are a tool to aid healthcare and insurance providers in lowering the cost of healthcare. They are much the same as any other audit, where someone reviews the paperwork and ensures that every piece of data is correct and matches the patient’s records and the healthcare provider’s notes. They’re typically conducted via software, which speeds up and improves the accuracy of the process.
3. How They Work
To perform an audit, a DRG auditor reviews both the diagnosis code the insurance provider was billed and the notes from the healthcare provider regarding the care his or her patient received. The diagnosis bill code must match the diagnosis that the healthcare provider noted and treated. If the data matches, the auditor moves on to the next record; if not, the auditor corrects the error and contacts the provider to adjust the payment amount.
DRG audits help ensure the bill an insurance provider receives matches the diagnosis and treatment a healthcare professional provided.