Using an expert system to ensure accurate third-party reimbursement

Many hospitals experience difficulties with Medicare reimbursements tied to payments strictly related to a diagnosis related group (DRG) in which a patient's stay is grouped or assigned. Potentially compounding these difficulties, many large third-party payers have also adopted the DRG system. A lack of knowledge of the intricacies of the DRG system on the part of physicians, administrators, or medical records managers often can lead to hospitals receiving considerably less reimbursement than they are entitled. A computerized coding system that incorporates an expert system can substantially increase reimbursements by simplifying the coding process, identifying overlooked diagnoses, and identifying any missing procedures.