Digital transformation case study

The real impact of SMART

A PwC Product

 

Coding quality improvement leads to $1.8M in net reimbursements

 

Client – US network of independent healthcare providers
Our Role – To support our client’s coding quality monitoring initiatives, PwC implemented SMART® Inpatient throughout the enterprise, with installations at 12 facilities; 11 inpatient and 1 behavioral health facility.
Industry Health services
Services Service Excellence, Digital

 

Situation:

Staying current with both coding and guideline updates and regulatory initiatives

A network of independent healthcare providers in New Jersey were striving to keep up with a rapidly changing regulatory environment. They were looking to leverage technology to monitor and improve inpatient coding quality on a pre-bill basis to promote both compliance with government regulations and obtain appropriate reimbursement to the institution for the services provided.

Solution:

How PwC implemented SMART® Inpatient throughout the enterprise

To support our client’s coding quality monitoring initiatives, PwC implemented SMART® Inpatient throughout the enterprise, with installations at 12 facilities; 11 inpatient and 1 behavioral health facility.

In addition to leveraging over 1,000 standard SMART edits, we worked hand-in-hand with our client to build and incorporate 35 custom edits to accommodate their specific organization initiatives. They were able to incorporate both coding and regulatory initiatives such as MS-DRG changes, CMS’ RAC initiative and Pay for Performance, as well as quality initiatives such as Patient Safety and Hospital Acquired Condition monitoring, to improve their inpatient coding quality.

“By incorporating pre-bill reviews into their workflow across the enterprise, they can stay on top of coding and regulatory requirements.”

Shannon O’Shea,Partner, PwC US


Results:

Seventeen percent of flagged cases reviewed by SMART required corrections, including a Diagnosis Related Group (DRG) revision in over half of the 5.5K cases flagged. The DRG revisions made by the SMART Quality Officers resulted in $13.9M in total claims revised.

"$1.8M in net reimbursement impact across the enterprise as a result of corrections identified by SMART."

Contact us

Neil Dhar

Neil Dhar

Vice Chair - Chief Clients Officer, PwC US