DRG Validation and Denial Management Challenges and Opportunities

As the healthcare industry moves to value-based payment programs, the dollars are tighter and the need for collaboration among clinicians, Clinical Documentation Improvement (CDI) specialists, and coders grows stronger. As providers get on board with managed care programs and more stringent fee-for-service requirements, payers are doing everything in their power to hold revenue dollars close. As a result, providers are struggling with payer-specific “Clinical Validation Denials” and constantly challenged on the codes and diagnostic related grouping (DRGs) they assign to cases.

This paper defines the process of DRG validation and how it can benefit provider organizations by ensuring that the correct information is communicated the first time.