recovered for healthcare providers
average recovery per underpaid claim
Accurate transfer Diagnosis Related Group (DRG) coding at the time of discharge is difficult, if not impossible, because it requires that the discharge staff knows what the patient will do in the future, not merely what the patient is advised to do or intends to do.
Medicare underpayments can occur when a patient is discharged as a “transfer,” but there is no post-acute care (PAC) billing. This often happens when a patient decides to forego the recommended PAC after discharge. When a patient elects not to transfer to a post-acute care facility in accordance with CMS rules, the discharging hospital is entitled to the full DRG payment but will have only received partial payment. In these cases, the burden of recuperating the full payment due falls on the facilities.
The Centers for Medicare and Medicaid (CMS) allows for a four-year retrospective review from the current date. If reasonable evidence is found showing that a claim was billed with an incorrect discharge status code, CMS allows reopening of that claim to adjust the code with “good cause.” CMS will not perform underpayment reviews on your facility’s behalf; providers are responsible for performing Transfer DRG reviews for their facilities.
eSolutions' Transfer DRG
eSolutions’ Transfer DRG can identify these claims, provide clear justification for the reopening of the claim, and make the adjustments on the facility’s behalf.
Transfer DRG is eSolutions’ proprietary software that allows us to conduct underpayment audits on behalf of your facility and ensure your reimbursement for those claims. Unless a specific underpayment audit is conducted for these cases, the revenue loss and the underpayments discovered will persist and continue to grow. Our automated processes require only a minimal data set to identify eligible claims, resulting in a fast turnaround.
Transfer DRG Success Stories
47-BED STAND-ALONE FACILITY
First-time Transfer DRG Review
eSolutions conducted a comprehensive three-year retrospective review of 100% of Medicare claims.
Although the client is a 47-bed facility, eSolutions uncovered a 4.96% total underpayment discovery rate across all Medicare claims reviewed. This resulted in more than $170,000 in additional DRG revenue for the hospital.
3,006-BED HEALTHCARE SYSTEM
12 locations throughout Central Texas
eSolutions conducted a comprehensive review of 100% of Medicare discharges. In addition to those eligible claims eSolutions found already adjusted during the primary vendors review, we also discovered claims that resulted in more than $800,000 in reimbursements to the health system – dollars that would have been lost if the health system had not engaged eSolutions for a secondary review. The health system is in talks to restructure its relationship on an ongoing basis.
$1.2 Million Recovered
204-BED STAND-ALONE FACILITY
Greater Los Angeles Metro Area
For new data received, eSolutions found $915,000 in underpayments.
eSolutions discovered nearly $340,000 in additional underpayment claims for the “second look” period overlapping data reviewed by previous vendor.
Total underpayments discovered during the 4-year retrospective review exceeded $1.2 million.