Diagnosis-Related Group Validation
Help improve diagnosis-related group (DRG) reimbursement accuracy with clinically defensible validation.
Clinical Validation
Reimbursement Accuracy
Accurate Diagnosis-Related Group (DRG) assignment is critical in supporting appropriate inpatient reimbursement.
Coding inconsistencies, unsupported severity levels, documentation gaps, and DRG upcoding can all lead to improper payments, increased audit risk, and unnecessary medical spend.
Claritev’s DRG Validation solution helps health plans improve payment accuracy through physician-led clinical review and advanced analytics that confirm diagnosis-related groups (DRGs) are supported by clinical documentation, ICD-10 coding, and applicable payment guidelines.
Available as both pre-payment integrity and post-payment integrity programs, our solution can identify payment inaccuracies before they affect your bottom line while helping to strengthen long-term payment integrity.
What Our DRG Validation Solution Evaluates
Claritev reviews inpatient claims to confirm that:
- Assigned diagnosis-related groups (DRGs) are clinically supported by the medical record
- Procedures are properly documented and billed
- Complication/Comorbidity (CC) and Major Complication/Comorbidity (MCC) assignments are supported by clinical evidence
- Claims are examined for common payment errors, including upcoding, sequencing issues, and unbundling
- Principal and secondary diagnoses are accurately coded
- Present on Admission (POA) indicators are accurate
- Claims are consistent with CMS and payer-specific coding guidelines
The goal is more accurate reimbursement, reduced financial leakage, and greater confidence in payment decisions.
How Diagnosis-Related Group (DRG) Validation Works
By combining advanced analytics with expert clinical review, Claritev helps payers confidently validate DRG accuracy and improve inpatient payment integrity.
Identify High-Risk Claims
Advanced analytics help identify inpatient claims with elevated risk for coding errors, documentation gaps, or inaccurate DRG assignment, allowing review resources to focus where they can deliver the greatest value.
Validate Clinical Documentation
Board-certified physicians, nurses, and certified coding specialists review medical records to determine whether diagnoses, procedures, severity levels, and clinical indicators support the assigned DRG.
Confirm Coding Accuracy
Our experts validate DRG grouping logic, ICD-10 coding, POA indicators, CC/MCC assignments, severity of illness, risk of mortality, and consistency with CMS guidelines.
Deliver Actionable Findings
Detailed findings are delivered through secure reporting workflows that provide clear clinical rationale, support disputes when needed, and help improve future payment accuracy.
Benefits of Claritev’s DRG Validation Solution
Improve Reimbursement Accuracy
Verify that inpatient payments accurately reflect documented clinical conditions, services provided, and applicable coding guidelines.
Strengthen Payment Integrity
Enable improved accuracy and consistency of inpatient reimbursement while helping reduce financial leakage.
Preserve Provider Relationships
Clinically supported findings and transparent communication help minimize provider abrasion while promoting accurate reimbursement.
Reduce Improper Payments
Help identify unsupported DRGs, inaccurate severity reporting, and coding inconsistencies that contribute to overpayments.
Support Compliance
Maintain alignment with CMS requirements, payer policies, and industry coding standards while supporting improved audit readiness.
Creating clear paths to value.
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Improve Payment Accuracy with Claritev
Claritev helps health plans improve DRG reimbursement accuracy by combining advanced analytics with physician-led clinical validation. Our comprehensive approach is designed to reduce improper payments, strengthen payment integrity, and support confident, evidence-based reimbursement decisions.