Every query from the health insurance fund costs more than checking the rules before the invoice goes out.
The case is coded, the DRG is determined and the invoice goes out. When a query arrives weeks later, someone has to piece together the file, the coding and the rule as they stood at the time. Until the answer is ready, the amount stays outstanding.
1caseAn inpatient case is coded and invoiced to the health insurance fund.
18checking rulesPrincipal and secondary diagnoses, length of stay and supplementary fees are checked against the rules.
6weeksThat is how long the case sits before the fund's query arrives.
2passesThe file is read a second time, this time without the original context.
There is no second pass six weeks later if the 18 rules are applied before the invoice goes out, and that is where the 40 to 60% less review effort comes from.
The 40 to 60% reduction in checking effort is this agent's headline figure. The number of rules, the waiting time and the second pass describe a typical query case in hospital billing; they are illustrative, not measured.