When patients come into a hospital to receive healthcare, they place their trust in the providers (and institution) that they will be treated correctly and fairly. This is especially true when it comes to being billed for items, services, procedures and tests that occurred during the medical visit.
One of the systems in place to help protect patients when it comes to billing is to enlist the help of a drg auditor.
What is a DRG?
Before you can understand what a DRG auditor does, it’s important to understand what DRG stands for. DRG stands for a Diagnosis-Related Group. This is essentially a system that helps classify patients into groups for the purpose of creating accurate billing and payment. The DRG system classifies diagnoses into more than 20 different sections (typically based on major body systems) and then subdivides them further into about 500 groups to make it easier for billing transparency.
There are many factors that are used in the DRG system including the actual diagnoses as well as the resources the hospital used to help treat the condition of the patient. Typically, hospitals will be paid a fixed rate for the services the correspond the appropriate DRG group.
What is a DRG Auditor?
A DRG auditor can come in the form of an actual person, or in the form of software to help automate and scale the process. At its root, a DRG audit is a way to review the process of how a patient is diagnosed and then how the claims were actually coded. The audit is simply a way to validate if the code that was billed to the patient matches the actual care the patient received.
While these audits/reviews are simple in nature, they are incredibly important to help hospitals protect themselves and rectify any patient overpayments as quickly as possible.