DRG/Clinical Chart Audit

Office of Inspector General conducted a study on Inpatient hospital stays and found that the number of stays at the highest severity level increased almost 20 percent from FY 2014 through FY 2019, ultimately accounting for nearly half of all Medicare spending on inpatient hospital stays. Stays at the highest severity level are vulnerable to inappropriate billing practices. Specifically, nearly a third of these stays lasted a particularly short amount of time and over half of the stays billed at the highest severity level had only one diagnosis qualifying them for payment at that level.

Most Payers, along with their Vendors and internal audit teams, conduct prospective and retrospective clinical review and validation of inpatient Diagnostic Related Group (DRG), Short Stay (SS), and readmission claims. The audits are conducted by highly skilled personnel that are in demand and difficult to hire. However, due to the lack of appropriate technology, most of these skilled auditors work on manual tasks that result in lower productivity.

AuditShark|DRG audit platform helps maximize the audit potential and skills or the auditors by providing them with technology and automation to improve accuracy and productivity. Our audit platform has features like workflow, edits, clinical data extraction from voluminous charts and insights to help audit accurately and efficiently.

Reference –


Improved productivity: Accelerate your audits with productivity boosting features like chart metadata extraction leveraging Natural Language Processing (NLP), edits and insights
Workflow: Build custom workflows to route claims to the right team members, ensure quality with peer reviews and escalate to medical directors based on your criteria
Provider abrasion: Insights help you better understand the drivers for provider abrasion and help you manage appeals from the system


Workflow – Customizable workflow to mimic your current flow and requirements
Rules – Configurable rules engine to help with maximizing productivity
Edits – Automatically flag claims that meet criteria for audit
Quality – configure peer review and escalations to medical teams
Data Extraction – Leverage Natural Language Processing (NLP) to extract metadata like ICD 10 codes, Procedure codes and clinical language from charts
Machine Learning – Leverage data to get insights into which DRG codes are up coded, which charts are leveraging robotic data rather than physician notes etc.