The effectiveness of a Transfer DRG second sweep can be explained in large part by the differences among vendor and internal processes.
- In some cases, only high dollar impact claims and obvious underpayments are examined during a primary review.
- Not all vendors utilize clinical expertise to conduct a clinical review of claims that are impacted by Transfer DRG rules. By including professionally trained clinicians in the process, additional underpayments can be identified in a compliant manner. Recovery processes that do not incorporate clinical expertise run a significant risk of compliance issues in their underpayment determinations.
- Certain vendors perform reviews within a short window of patient discharge. This practice may not allow enough time for post-acute providers to submit their billing information, leading to an incomplete picture of the care received by a patient during the entire spell of illness, and ultimately to missed or incorrectly identified opportunities.
- Some reviewers who are not as experienced with all of the nuances of the Transfer DRG rules may review only certain discharge status codes, leaving substantial revenue unrecovered. Worse, reviewers who are not intimately familiar with Medicare claim and eligibility data may identify underpayments that are not compliant recoveries, or that have previously been recovered by a Recovery Audit Contractors (RACs), leading to wasted hospital staff time.
- Finally, certain reviews may needlessly eliminate opportunities from consideration due to the presence of related reimbursement factors such as Medicare Secondary Payer. Without a clear understanding of how all of the relevant reimbursement and clinical factors impact the final claim payment, Transfer DRG revenue recovery opportunities may be missed.
