Vendor change for commercial DRG audits beginning June 2024

Blue Cross Blue Shield of Michigan previously worked with Change Healthcare to perform commercial diagnosis-related group, or DRG, validation audits as part of the Payment Integrity Program. Change Healthcare has been acquired by Optum.  

Optum, an independent company, will provide auditing support for Blue Cross by performing claim audits on inpatient hospital DRG claims beginning in June 2024.

The audits will:

• Focus on DRG coding and clinical validation.
• Review data going back to January 2024.
• Base the look-back date on the date the claim was paid.
• Require health care providers to submit medical records.

Medical records will be reviewed to:

• Facilitate accurate claim payments.
• Detect, prevent, and correct fraud, waste and abuse.

You’ll need to provide medical records for review at the time of an audit. After an audit, Optum will send you a determination letter that details information on how to request an appeal.

If you have questions, contact an Optum provider service representative at 1-877-787-2310 from 8 a.m. to 4 p.m. Eastern time Monday through Friday.