DRG Claims

Website: https://www.drgclaims.com/

DRG Claims Management (DCM) has been offering cost containment solutions to health plans across the United States since 2013. Our services include:

• Hospital Claim Audits (MS/APR DRGs and APC)
• Additional hospital audits
• Cost Outliers
• Readmissions
• Short-Stay/OBS
• Skilled Nursing Facility (PDPM/RUGs) audits

Our models include:

Post-payment Model: Focuses on addressing inaccurate coding and clinical errors retrospectively, maintaining good relationships with providers, and ensuring a smooth refund request process.

Prepayment Model: Preferred by health plans to prevent overpayments, reduce turnaround time, increase provider response, and ensure the audit of out-of-network claims.

MedReview

Website: https://www.medreview.us/

MedReview sets itself apart with over 50 years of experience delivering physician-approved pre-pay and post-pay payment integrity services that prioritize billing and payment quality, accuracy, and precision. Every claim reassigned by MedReview is reviewed, approved, and documented by a team of physicians, resulting in the industry’s lowest appeal overturn rate. 

Utilizing proprietary technology combined with extensive subject matter clinical and administrative expertise, we achieve a 40% or greater reassignment rate focused on our clients’ specific needs. MedReview provides the full spectrum of payment integrity solutions including DRG and clinical reviews, cost outlier audits, re-admission reviews, data mining and itemized bill reviews. 

Partnered with clients across the country, MedReview offers a flexible approach, supporting both complete outsourcing and supplemental enhancements to existing programs. By optimizing recoveries, preventing overpayments, and improving the provider experience, MedReview empowers payors to navigate the complexities of payment integrity with confidence and measurable success. 

Carelon

Website: https://www.carelon.com/

The health of the healthcare system improves when spending is responsible and accurate. Today, platform technology and advanced analytics are paving the way to make that more efficient and more proactive than ever before.  Backed by decades of experience, Carelon’s Payment Integrity solutions bring together breakthrough technology and human expertise to help speed your ability to drive cost savings and value for your stakeholders.