Executive Summary
Directional screening estimate — actual recovery may be higher or lower.
Potential payer underpayment opportunity.
Claims can appear fully paid while contract terms, payer edits, and payment methodologies leave reimbursement below what the hospital may be entitled to receive.
Purpose-built analytics screen claim populations for payment discrepancies tied to payer-specific reimbursement methodologies. Experienced auditors validate potential underpayments before recovery action.
Current screening model uses reported hospital beds and GRT historical recovery assumptions to estimate the annual payer underpayment review opportunity.
Potential additional DRG reimbursement.
Discharge disposition and downstream care information may not be available when the claim is first paid, allowing a qualifying claim to remain reimbursed under transfer or per-diem logic.
Calculates qualifying discharges paying at per diem under DRG and utilizes information outside of provider data to validate discharge/related-care status.
GRT screens 1.0% of inpatient volume for full-DRG transfer opportunities and 0.2% for home-health unrelated-care opportunities. Traditional Medicare recovery is counted at 100%; only 75% of modeled Medicare Advantage recovery is included, with 25% assumed uncollectable. Payment per case follows the GRT hospital CCN ranking.
Potential uncaptured teaching reimbursement.
The Medicare Advantage claim can be paid while the separate Medicare teaching-payment claim is never generated, rejects, or remains unresolved.
Identifies all MA-eligible patients and validates whether the shadow bill was submitted and accepted by Medicare.
The estimate is 7% of reported Medicare Advantage IME and net DGME reimbursements in the selected Medicare cost report. If either required reported amount is unavailable, no estimate is calculated (TBD). No teaching-hospital or discharge-based fallback is used.
Potential missed add-on reimbursement.
The qualifying technology may be present without the required claim coding, or the claim may pay without the expected add-on amount being identified and followed up.
Match qualifying technology, required claim coding, and the Medicare payment calculation at the claim level.
Medicare inpatient volume is combined with GRT screening assumptions for qualifying technology utilization and incremental add-on reimbursement.
Estimates are based on publicly available hospital data and GRT screening assumptions. Actual results may be higher or lower depending on provider-specific claim populations and validation. This is not a guarantee of reimbursement.
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