We conduct audits of hospital bills for health care insurance companies and providers of medical reimbursement services by using Checkpoint DRG, which safeguards accurate health insurance settlements in hospitals. Our software checks diagnosis and procedure codes and links these to validation rules that are based on various code sets (e.g. ICD codes). The software based validation rules check, if a case is a potential outpatient in regards to the Ambulatory Patient Group (APG) payment methodology for hospital-based outpatient services. In addition, all cases are comprehensively examined for medical plausibility by experienced physicians, nursing staff, and medical coding specialists, thereby allowing us to carry out efficient workflows.
DRG auditors identify potential errors in the hospital claims data. Upon demand, they will review the adequacy of the medical records and adjust errors accordingly. Many extensive rules and standards have to be applied skillfully to ensure that only few cases must be reviewed manually. Our professional auditor team works closely with clients and delivers reports concerning potential audit problems and result information on a regular basis. Our long-term experience with DRG systems permits us to conduct DRG audits efficiently and on a high level while keeping costs low.
For an analysis of comprehensive data sets, it is essential to implement complex test algorithms and software based validation rules, which are edited electronically. We adjust and update the system on a continuous basis. While applying these complex rules, we are able to swiftly analyze large case numbers, filter out any case constellations of high error potential as well as determine cases for manual review. Our rule based audit system searches and identifies non-accurate coding. The relevant cases are then checked according to coding quality and plausibility. After the potential error has been identified, we subsequently contact the responsible hospital officials and formulate customized inquiries. The results of these negotiations enable us to further conduct substantiated audits.
The medical bills are examined and compared to the AEP Protocol, which consists of a set of admission criteria and a set of day-of-care criteria related to patient severity of illness and the clinical services required. The criteria are independent of diagnosis or body system and are applicable to all patients.
We review the claim and the medical bill on the basis of additional existing medical patient information to determine if the patient can be categorized as a potential outpatient, since the length of stay determines the hospital costs. In regard to the criteria listed in the AEP, the care provider’s obligations should be assessed.
We seek direct contact to health care service providers concerning open inquiries. However, should all parties not mutually agree, we will create a well-founded report for our customers.