- Is there value to having an IME safety net when you are on Epic?
Yes there is value. Our process makes sure there isn’t anything left behind as well as makes sure nothing was registered incorrectly or a new insurance was not added incorrectly. - If you use a primary vendor for Transfer DRG, should you use a secondary vendor?
Yes, 100%! Best practice is to use a primary and secondary vendor. This will ensure nothing is left behind and it keeps everyone working hard. - Can you review any other payors than Medicare for DRG Validation?
BESLER can review all payors that reimburse based on a MSDRG or an AP or APR DRG. There is opportunity to potentially optimize reimbursement for each of them. - What are the timely limits for submitting an updated DRG for DRG validation?
For Medicare, you have 60 days from the initial payment to submit for a DRG change. For the other payors, the timely filing varies based on your specific contracts. We find there is up to 365 days to submit the DRG change, but it depends on the contract. - Is there a heavy IT lift for any of your services?
The only IT lift there is for any of our services is to supply the 837s and 835s. There is minimal start up time because there is such little IT involvement. - How do you determine what claims to review for DRG validation?
BESLER reviews 100% of all the claims reimbursed on a DRG, and then our bank of rules target claims that have a likelihood of being potentially under-coded. The team will then review the flagged claims utilizing the 837 information and EMR access to determine if there is potential optimization. - Is your process for DRG validation pre- or post-bill?
Our review is post-bill and post all your pre-bill validation steps you have in place. BESLER makes sure there is nothing left behind post-bill. - Does performing a post-bill review for DRG validation increase post-bill reviews by Medicare or Medicare Advantage?
We do not find this increases post-bill audits for any of the payors. We have been performing post-bill review for 10 years and have not seen any post-bill reviews for Medicare focused on coding. Medicare Advantage has post-bill reviews, but is not related to the updated claim. They tend to do post-bill reviews as a standard practice; our recommended changes are coding compliant and always approved by you and does not negatively impact the review. In addition, BESLER will help with clinical information/documentation needed for an appeal. - Are there a lot of rejections and take backs from Medicare for Transfer DRG?
BESLER has a strong compliance process in validating the post-acute care provided to include calls to the post-acute providers. Rarely, do we see rejections, and BESLER has never lost any reimbursement due to the discharge status code change. We have highly skilled billers who know how to get claims paid correctly. - What is the average reimbursement impact for DRG Validation changes and Transfer DRG changes?
For DRG Validation, we find the average impact to be $3,000, and the average impact for Transfer DRG is $3,800. For both services, we see impact amounts close to $100,000 in some cases. The impact for both is significant enough to warrant doing both reviews as a standard business practice.
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