During a featured session at Becker's 9th Annual Health IT + Digital Health + RCM Conference, CorroHealth's Senior VP Samuel Dominik, and Senior VP of Clinical Documentation and DRG Integrity Bilal Mushtaq, MD, discussed the complexity of Diagnosis-Related Groups (DRGs) revenue integrity and the financial pressures faced by hospitals.
Macro trends affecting hospitals, such as Medicare Advantage and shifting coding requirements have led to increased DRG downgrades and denials. The speakers emphasized the importance of data analytics, accurate clinical documentation and second-level reviews to prevent denials.
Four takeaways:
- Staff shortages and clinician turnover often result in inconsistent documentation and revenue leakage.
"Retention is a big problem on CDI teams. Health systems make some investment in training these folks and then it's not long before they're off to some other opportunity." - Dr. Bilal Mushtaq - Technology solutions can help identify revenue-saving documentation and coding opportunities.
"This is where healthcare organizations can really use data to their advantage when they have something like this in hand. It can really help find revenue leakage. It also helps on the compliance side and can address under- and over-coding." - Dr. Bilal Mushtaq - The shift towards more Medicare Advantage patients has increased the risk of DRG downgrades, leading to a mismatch between the cost of care and the reimbursement received by hospitals.
"When the Medicare Advantage final rule came out last year, it really reset some of the rules of engagement. What it's done is fueled a lot of DRG downgrades and denials." - Sam Dominik - Hospitals need to proactively engage with payers and quantify the impact of DRG downgrades for more successful contract renegotiations.
"This information is critical to bring when it comes time to sit down at the negotiation table with a payer. You can point to it and say, 'this is what DRG downgrades are costing me.'" - Sam Dominik