CodeGuard: pre bill claim validation for denials and DRG downgrades
Flags risk, explains why, and packages evidence for hospital billing staff decision making before billing submission.
Outcomes we target
Clean-claim defensibility at submission
Fewer rework cycles per claim
Shorter discharge-to-defensible-submission time
Lower appeal packaging burden
More predictable cash timing
Why now
54.3% of denied claims were ultimately overturned (Premier via AHA).
Average denial tied to charges of $14,000+ (Premier via AHA).
$19.7B spent in 2022 pursuing denied-claim overturns (AHA).
Outputs your team can act on
CodeGuard produces review ready outputs that tie each risk signal to record evidence and the basis used.
Risk summary
What is at risk and what to review first.
Driver rationale
The driver and the reasoning in plain language.
Evidence packet
Record excerpts plus linked basis references.
Action list
The smallest set of fixes that change the outcome, with ownership.
Where it fits in the workflow
CodeGuard runs before billing submission, when teams still have leverage to fix documentation and coding vulnerabilities.
Case closes
Documentation and coding still evolving.
CDI and coding in progress
Clarifications still possible.
Pre bill validation review
Risks surfaced with evidence.
Billing submission
Send cleaner claims, fewer surprises.
How it stays defensible
Human decisioning plus evidence anchoring, designed for reviewability.
Human decisioning
Recommendations, not auto changes. Your team approves actions and escalation stays yours.
Evidence anchored
Record excerpts and basis references included so rationale is auditable.