Diagnosis Related Group (DRG) Program Review Effective Date For Medicare Advantage

In a continuing effort to manage and control health care costs on behalf of our members, Blue Cross NC implemented Diagnosis Related Group (DRG) reviews for our Medicare Advantage members effective January 1, 2023, as indicated in the Blue Cross NC communication linked below. This program was implemented to maintain accuracy in claims payment by ensuring claims are not overpaid or underpaid, in accordance with Blue Cross NC contract terms and polices.  Reviews will be performed on a prepayment and post-payment basis.  Post-payment reviews will apply to claims paid within the last 18 months.  All DRG claims will be subject to review, however not every claim will be selected for review.

Claim Review Service

Currently, our vendors perform post-pay DRG validation reviews to confirm correct coding and billing. The DRG payment methodology was created as an effective framework to standardize utilization of services.  Clinical coder reviewers validate the diagnoses and procedures that affect the DRG and ensure diagnostic and procedural information and the beneficiary’s discharge status is consistent with the attending physician’s description and the medical record information.

The review will apply to claims including but not limited to:

• Overpayments
• Underpayments
• Discrepancies in ICD-10 and procedural coding

Providers may see an increase in communications and requests from vendors that are performing the reviews on behalf of Blue Cross NC.  When requested, providers can submit medical records and schedule in-person reviews (when applicable) without seeking member authorization.

For information on the DRG reviews for our Fully Insured, and Small Group, Administrative Services Only (ASO), Individual, State Health Plan and IPP/Blue Card Program please refer to previously published communication: Diagnosis Related Group (DRG) Program Review Effective Date for Medicare Advantage (11-01-22).

These programs will not include the Federal Employee Program market segments at this time.