Whether you are looking for pre or post pay recovery audit services, or want to ensure payment accuracy for your paid claims, VARIS can assist your health plan with our suite of services. VARIS works with all types of health plans and payment arrangements including Medicare Advantage, Medicaid Managed Care, Commercial, State Medicaid, Administrative Service Organization (ASO) and Medical Service Organization (MSO). We work with an array of plan types from Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), and Point of Service (POS). Health Plan clients range in member size from 2,000 members to over 16+ million members.
Inpatient DRG Review
Diagnosis Related Groups (DRGs) prospective payment system is a system of classifying inpatient hospital patients who have similar hospital resource use and length of stay into distinct groupings. The groupings are based on diagnoses, procedures, age, sex, discharge status and the presence of complications or comorbidities. The DRGs are used to determine acute hospital reimbursement.
Our audit services validate the diagnosis, procedures, age, sex, discharge status and presence of complications or comorbidities for accuracy of payment.
VARIS is well versed in auditing all types of DRG variations such as APR-DRG, MS-DRG, CMS-DRG, AP-DRG, and TRICARE-DRG.
The Ambulatory Payment Classification (APC) prospective payment system is a system design to define and explain the amount and type of resources used during a single outpatient visit. APCs are defined solely on the CPT procedure codes. In arriving at a final payment amount for each visit, the system packages certain predefined services performed during the same visit. These services include those that do not require significant added time and resources or that are routinely performed with certain diagnoses and/or procedures, such as x-rays and casting a fracture. APCs are used to determine outpatient hospital reimbursement.
Our audit services validate the CPT procedure codes and other factors for payment accuracy.
Clinical Validation is an additional process that may be performed along with DRG Complex Chart Reviews to ensure accuracy of payments. Clinical Validation involves a clinical review of the cases to determine whether or not the patient truly possesses the condition that was documented in the medical record. Diagnoses documented in the patient’s medical records must be substantiated by clinical criteria generally accepted by the medical community. This may result in claims denial when the clinical indicators in the record do not support the reported diagnoses and procedures.
The review may be completed in either a pre-pay or post-payment environment.
The leveling of Emergency Room services (ER/ED Leveling) ensures that Emergency Room providers (facilities and physicians) are reimbursed based on the code or codes that correctly describe the health care services provided.
Facility coding guidelines are inherently different from professional coding guidelines. Facility coding reflects the volume and intensity of resources utilized by the facility to provide patient care. Whereas professional coding is determined based on the complexity and intensity of provider performed work and include the expertise expended by each provider.
ED Leveling audits are conducted more for compliance versus recovery opportunities.
The goal of VARIS’ readmissions program is to assist health plans in recovering dollars spent unnecessarily by identifying potentially preventable readmissions within a 30-day time period. All readmissions reviews are conducted by an experienced team of Registered Nurses and physicians.
Readmission reviews utilize CMS’ requirements and/or health plan specific policies.
Based upon the client’s interaction with our service and expertise, we have been able to provide additional consulting projects to meet the health plan’s immediate needs, such as:
- Onsite coding review for fraud for individual providers
- Desk coding review for fraud for individual providers
- Coding compliance reviews for individual providers
- Coding crosswalk from state to federal codes
- Medical record review for unlisted codes and code assignment
- Financial analysis per diem to APR-DRG methodology health plan wide
- Financial analysis per diem to APR-DRG methodology individual provider contracts
- Financial analysis MS-DRG to APR-DRG methodology health plan wide
- Expert witness testimony, etc.