Advanced analytics-driven DRG clinical auditing solutions resulted in significant improved savings
One of our long-standing payer clients was looking to streamline their payment integrity program, specifically their Diagnosis-Related Group (DRG) auditing solutions. A DRG is a classification system that groups any hospital inpatient stay for the purposes of payment. DRG audits review the patient case, diagnosis, treatment, and claim coding, and validate that the coding and DRG assignments accurately reflect the payment.
Our client’s payment integrity program had eight different vendor organizations. Having so many vendors was a challenge for the entire health plan team, as they had to repeat and duplicate the process for each of the vendors – everything from accounting to data management to reporting. This inefficient process caused the organization time, money, and resources.
As their most trusted and first-pass post-pay vendor for DRG coding and clinical auditing services, they approached EXL when looking to reduce vendors to decrease administrative and operational workloads within vendor management. EXL had recently switched from a program-centric to a client-centric delivery model, and this new approach dedicated one team to partner with our client to address and solve their complex business challenges.
EXL’s dedicated team engaged the client to better understand their challenges and determine their short- and long-term goals. Leveraging our deep domain expertise, the dedicated team conducted thorough investigative reviews to determine a roadmap and put those concepts into production. First, the team invested heavily in analytics and identified areas where traditional audits historically hadn’t been conducted. Second, they reviewed the entire claim lifecycle – from inpatient to treatment to readmission – looking for patterns and outliers among diagnosis codes, providers, and locations.
The fully outsourced solution was largely enhanced through significant investments on the analytics-drive model. EXL is now their largest cost containment vendor from a savings perspective.
The entire DRG clinical auditing approach received a full overhaul, and most importantly, led to substantial DRG reimbursement savings.
Combining human ingenuity, technology, and analytics-enabled solutions, EXL’s payment integrity solution was able to impact payment accuracies, cost management, and quality outcomes – all key to value-based performance success.
By partnering with our client to better understand their needs and implement custom solutions, EXL Health was able to create significant value to the organization. These rigorous efforts to implement a strategic process and expand the scope of work yielded an improved savings rate of 120% within 2020 and 2021.
- 30% overall DRG savings for client in 2020
- 56% overall DRG savings for client in 2021
- Expected continued growth in 2022
- Improved resource efficiency due to streamlining from a singular vendor