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Learn how one health system is tackling DRG downgrades and frequent charge audits.

Chelsea Raukar at M Health Fairview Discusses Payer Challenges and Remedies

Learn how one health system is tackling DRG downgrades and frequent charge audits.

What are some examples of successful remedies to payer shifts you're seeing?

Chelsea Raukar: "We're seeing a lot in terms of DRG downgrades, so we're having to shift our perspective into trying to proactively advocate to not only get paid for the services that we provide but also make sure that we're able to keep the money that we're getting. So we've assembled a dedicated denials prevention unit that's starting to focus on tracking and trending, we're working on strengthening our partnership with Utilization Review, and we're also launching some new services for Fairview with an emphasis on physician advisor and review groups. So that's kind of one of the trends that we're seeing.

"Another thing that I could say in terms of payer behavior is we're seeing an increase in charge audits, where they're challenging line-by-line things that are considered to be bundled with other services or room and board services. And we're seeing payers partner with vendors, sometimes multiple vendors per payer. So we're working on creating some tracking and some strategy to address the increase in charge audits that we've been seeing to make sure that we can trend who we're getting these audits from, what type of things they're targeting, and whether we win them or not. If we do win them, then we need to make sure that we still have the appropriate payment applied to the accounts. And we're actually seeing where, for example, one payer will partner with maybe three or four different external vendors to conduct these charge audits on their behalf, and they'll give them the same book of business. So we'll have one audit on one account, and then six months later we'll see a different vendor auditing the same exact account that we had just appealed and won on. And so that's a payer behavior that we're working on putting a little bit more intentional tracking and strategy to, so that we can give that feedback to our payer relations group and say, 'Hey, you know what, if we've won this many audits this many times, let's make a deal not to audit us on that thing anymore. Or if you've already audited us once, then let's narrow it down to only one vendor that you're having conduct audits on your behalf, so that you're not creating this excessive administrative burden on our teams.'"