Case Study: DRG Validation Identifies $3.2M in New Reimbursements

Caucasian nurse checking data in office


A large health system in the Northwestern United States needed help identifying reimbursement opportunities and slowing its significant revenue leakage. The organization made considerable investments in computer-assisted coding (CAC) and an internal coding team dedicated to quality improvement. Despite the investment in new solutions, the health system still experienced significant revenue leakage.


R1 DRG Validation was implemented to target potential coding anomalies and/or documentation improvement opportunities. The implementation required minimal IT involvement from the health system. R1’s credentialed auditing staff provided the health system a much-needed expansion of resources to ensure coding accuracy.


Within the first year, R1 identified $3.2 million in reimbursement. DRG Validation delivered improvements in case mix index (CMI), accuracy, compliance and quality, resulting in an 83% agreement rate. Errors were identified and corrected, improving indirect value by 20%. R1 DRG Validation allows the health system to make continual DRG improvements via intuitive dashboards and feedback reports.

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