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 will begin implementing Diagnosis Related Group (DRG) reviews for our Medicare Advantage members effective January 1, 2023. This program is being implemented to maintain accuracy in claims payment by ensuring claims are not overpaid or underpaid.  Reviews will be performed on a prepayment and post payment basis. All DRG claims will be subject to review.

Blue Cross NC has communicated previously correct coding requirements i.e. billing for routine supplies, routine services, and upcoding. All reviews will apply to claims paid within the last 18 months.  

Claim Review Service Vendor

Equian, LLC will perform analytics on claims that will include but not limited to: 

• Overpayments 
  
• Underpayments 
• Discrepancies in coding (such as upcoding)  

Once the DRG program has been implemented, providers may see an increase in communications and requests from Equian, LLC regarding their claims. When requested, providers can submit medical records and schedule in-person audits (when applicable) without seeking member authorization. 

Please review our previous communication about DRG reviews for our Fully Insured, and Small Group, Administrative Services Only (ASO), Individual, State Health Plan and IPP/Blue Card Program.   

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