A New VISION is Reshaping DRG and Revenue Integrity in Healthcare
11 Dec 2023
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Source: FierceHealthcare
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CorroHealth reveals new technology dedicated to optimizing DRG and Revenue Integrity.
With the healthcare industry grappling with a shortage of skilled professionals and payer denials, including DRG downgrades, hospitals across the U.S. face heavy financial headwinds. These issues are intensified by the complexities of Clinical Documentation Integrity (CDI), which is crucial for DRG revenue integrity.
Dr. Bilal Mushtaq, MD, MBA, Senior Vice President of DRG Revenue Integrity at CorroHealth, states, “Around 2016, Payers shifted to clinical validation over coding validation denials, and the annual changes in coding guidelines each October add to the complexities in Clinical documentation improvement initiatives for both staff and providers.”
According to Dr. Mushtaq, a gap in medical education regarding documentation leads to ongoing challenges in the field. He also points out the resulting physician fatigue, especially in documentation queries, and the effects of COVID-19 in the healthcare industry, which have led to suboptimal documentation practices and responses like 'unable to determine.’ These factors considerably affect CDI accuracy, thus impacting DRG and revenue integrity.
The Vital Role of DRG in Reimbursement Accuracy
Accurate and comprehensive clinical documentation, facilitated by effective CDI practices, is crucial. When DRGs are correctly assigned, they reflect a patient’s true care complexity and resource needs. Incorrect DRG classification leads to underestimation of the resources, resulting in inaccurate or undervalued reimbursement.
Additionally, incorrect DRGs affect the Case Mix Index (CMI), a vital metric representing the average severity and resource consumption of a hospital's patient population. The synergy between optimized DRGs and an accurate CMI forms the backbone of a financially robust and fair healthcare reimbursement system, ensuring institutions are adequately compensated for the level of care provided. By focusing on accurately documenting and coding to the correct CMI, healthcare providers can strategically navigate revenue cycle management challenges, securing financial stability and sustainability. However, this requires resources that know and understand the intricate DRG system and keeping up with the ever-changing system is challenging.
Utilizing CMI for Benchmarking
CMI benchmarking is a strategic tool which hospitals can use to navigate the complexities of CDI and DRG integrity. Defined by CMS as the average DRG weight per inpatient discharge, CMI indicates a patient’s stay complexity and resource needs. Benchmarking helps hospitals compare their performance to industry peers, highlighting opportunities to enhance DRGs for improved financial results. For instance, lower CMI facilities can pinpoint and rectify gaps in clinical documentation, ensuring accurate DRG capture. By utilizing CMI benchmarking, healthcare providers can pinpoint where they need to improve their processes and education. Additionally, the CMI metric can be used within automation platforms, like in VISION by CorroHealth, to improve DRG integrity, giving providers a strategic tool that’s both intelligent and automated.
The Role of AI Technologies in Streamlining Healthcare
Recent Artificial Intelligence (AI) advancements have introduced transformative solutions to the healthcare sector. Integrating AI, machine learning, and data analytics, these technologies can transform patient care management and documentation practices.
VISION by CorroHealth is at the forefront of these innovations, specifically developed to enhance DRG integrity and CDI. Unlike conventional AI models, VISION instantly identifies, scores, and prioritizes clinical cases for pre-bill secondary reviews, boosting revenue by 4x to 10x. Its unique, adaptive scoring system is continuously refined through feedback and regulatory updates. Powered by proprietary algorithms rooted in clinical expertise, VISION employs advanced healthcare analytics for peer benchmarking and precise calibration to specific hospital environments. This ensures billing and coding accurately reflect patient care, which is vital for fair reimbursement and revenue integrity.
Distinguishing VISION in the Market
What sets VISION apart is its comprehensive approach, combining technology with bespoke solutions. While some platforms offer limited tech-only or service-only options, VISION provides a balanced blend, ensuring that technology and service needs are met. This approach is critical for boosting CDI and Health Information Management (HIM) team performance, optimizing DRG, and accurately reflecting patient care complexity.
CorroHealth aims to empower healthcare providers with technology and solutions that improve revenue capture and accurately report patient care nuances. VISION equips providers with the necessary tools to master CDI challenges, ensuring precise documentation and effective DRG capture for sustained financial health. Do you need to improve DRG and revenue Integrity? Connect with CorroHealth now for a strategic deep dive into your clinical revenue cycle and empower your CDI and HIM teams.
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