The Industry Landscape
Pressure to Scale DRG Reviews with Precision
For healthcare payers, ensuring the accuracy and integrity of inpatient claims is non-negotiable. DRG reviews are essential to validating provider-submitted healthcare claims, yet traditional models are increasingly strained by rising claim volumes, diverse plan types and shifting regulatory requirements.
To keep pace, payers need a smarter solution that fuses advanced automation with clinical expertise. By integrating technology and human expertise, organizations can transform their healthcare payer operations review for scalable execution, regulatory compliance and cost optimization without compromising precision.
The Challenge
Modernizing a Manual, Scattered Review Function
The client faced significant limitations in its DRG review operations. Its legacy model was built on highly manual processes and siloed tools, resulting in:
Manual data transfer
between systems, which delayed reviews and introduced errors
Scalability challenges
that made it difficult to manage volume spikes
Lack of real-time visibility
into review queues and workforce performance
Limited Quality Assurance (QA) infrastructure
that constrained audit readiness and process control
To stay ahead of rising claim complexity and regulatory demands, the client needed a modern, agile operating model that could streamline processes, enhance accuracy and support scalable, data-driven reviews.
The Solution
A Digitally Enabled, Scalable DRG Model
As a digital-led business transformation and services partner specializing in healthcare automation, WNS deployed a holistic, transformation-focused engagement designed to harmonize smart automation with expert review capabilities. Our solution emphasized:
1. Enhanced Process Design
We streamlined the DRG workflow with embedded QA checkpoints, real-time status tracking and a unified interface for clinical reviewers.
2. Integrated Quality and Capacity Management
Analytics-powered dashboards enabled dynamic capacity forecasting, transparent productivity tracking and continuous quality improvement.
3. Targeted Project Execution
A dedicated team handled backlogs and complex DRG scenarios, allowing core operations to maintain stability and focus.
4. Training and Scalability Enablement
Structured onboarding and performance-based training accelerated ramp-up and ensured the model could scale on demand.
The Outcome
Scalable Review Operations with Strategic Impact
The re-imagined DRG model delivered measurable gains in cost, speed and quality:
percent reduction in operational costs
through workflow optimization and resource
re-alignment
percent faster turnaround times
on high-volume DRG reviews
- percent improvement
in process knowledge
Improved audit performance supported by integrated QA frameworks
Scalable operating model
that can flex to meet growing volume without diluting quality
FAQs
1. What are the challenges healthcare payers face in DRG reviews?
Healthcare payers face challenges such as high claim volumes, manual and inconsistent review processes, limited visibility into coding accuracy, regulatory complexity, and difficulty scaling operations while maintaining audit compliance and quality.
2. How does automation enhance DRG review operations?
Automation streamlines DRG reviews by standardizing workflows, reducing manual effort, and enabling faster identification of coding discrepancies. Automated task routing and rule-based validations help improve accuracy, consistency, and turnaround times.
3. What role does analytics play in scaling DRG review operations?
Analytics enables payers to prioritize high-risk claims, identify patterns in coding errors, and continuously improve review strategies. Data-driven insights support better resource allocation and scalable operations without compromising quality.
4. How can WNS’s solution improve process knowledge and audit readiness?
WNS embeds structured workflows, documentation, and audit trails into DRG review processes. This improves institutional process knowledge, ensures consistent execution, and enhances audit readiness by providing transparency and traceability across reviews.
5. What are the measurable outcomes of modernizing DRG review operations with WNS?
Modernizing DRG review operations with WNS leads to faster turnaround times, improved coding accuracy, enhanced compliance, better scalability, and increased recovery opportunities while maintaining consistent quality standards.