Commercial Insurance

Our CDI team currently reviews inpatient medicare and medicare managed care accounts. We are considering adding commercial insurance patients. Are there different opportunities or considerations for commercial insurances? Thanks


  • commercial insurances often do not pay per DRG like Medicare, they often contract for per diem rates or other types of payment. it might be helpful for you to understand how your major commercial payers identify reimbursement rates as well as any other contract considerations related to denials/appeals etc. and trends that the hospital is seeing about what records are challenged.

    In general, I tell people to treat the charts all the same. Work to obtain the best documentation possible to support SOI/ROM. accurate DRG assignment and risk adjustment. there are so many different payer arrangements you can in know way look at them all and productivity would slow if you had to adjust your review focus differently for each payer.
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