Inpatient & Facility Audits

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Performant Healthcare Solutions provides correct coding evaluation along with evidence-based clinical validation via complex claim review to ensure payment integrity in both Medicare Severity-Diagnosis Related Group (MS-DRG) and All Patients Refined (APR) DRG inpatient facility claims. As a CMS RAC auditor, Performant has extensive experience applying CMS policies to DRG reviews. With more than 10 years of experience, and thousands of coding and clinical validation audits completed every month, Performant has developed a process differentiated on two key factors: 

  • Track-record of extraordinary customer service for health plans, including collaborative working relationships with client liaisons and a tailored audit strategy and implementation plan that focuses on long-term results.

  • Proven DRG review capability that consistently earns the highest accuracy scores (99.7%) for the largest audit recovery program in the nation. 

We help control claims costs with a technical, clinical, and practical approach to identifying coding and sequencing errors or services not supported by the medical record. We apply standard MS-DRG coding rules for CMS and national payers and maintain a comprehensive library of DRG clinical validation concepts. These concepts are fully documented and reviewed with each health plan to ensure evidence-based clinical guidelines are appropriately applied to the specifics of each health plan’s policies, prior-authorization rules, and other clinical guidelines. Performant also delivers Medicaid APR DRG audits for dozens of state Managed Care Organizations (MCO)s.

As part of our acute inpatient DRG audit program, Performant offers short stay or place of service audits, applying plan policies toward inpatient admissions, observation time frames, and application of non-Inpatient Only List (IOL) services.