How we start
Prove it, then scale once earned.
We begin with a retrospective analysis to quantify preventable downcodes and clinical denials using your historical claims. If the results are promising, we move to a limited pilot on live claims. No integration or workflow changes to start. Exports are enough.
How we engage
We aim to provide actionable, citable evidence-linked guidance your team can validate. Key metrics are grounded in accuracy and defensibility.
1. Pre-Pilot: Retrospective proof (3 to 6 weeks)
Blind run on a targeted set of cases, then validate against remits. You get dollars at risk, root causes, and a clear go or no-go.
2. Pilot: Live validation (with guarded scope)
Support live claims in the same narrow scope using your existing worklist. Measure prevented downcodes, prevented denials, and reduced rework. Send results to your hospital billing staff for final decision pre-bill.
3. Scale: Ongoing monitoring and expansion
Expand DRGs, payers, and sites. Continuous monitoring of payer patterns.
Pre-Pilot: What Happens
What we do
- Select a focused set of cases (your highest-friction DRGs (sepsis, heart failure, etc.) and payers)
- Run CodeGuard without seeing outcomes first, and
- Produce encounter-level findings with evidence links: what is supported, what is missing, and what is likely to trigger payer pushback.
What you provide
- A limited, scoped export for the target cases.
- No EHR integration required to start.
- We review outcomes only after we deliver initial findings.
How results are validated
Once you share adjudication and remittance outcomes, we run a delta review: where CodeGuard matched payer outcome, where it disagreed, and why (documentation gap, coding choice, payer pattern, or workflow issue).
What you get
- Executive summary with dollars at risk tied to specific driver buckets, and recommended next steps
- Driver map: payers, DRGs, and top root causes
- Evidence-linked encounter examples: fast validation for CDI, coding, and RCM
- Pilot scope recommendation: what to test first if you proceed
Want to learn more?
In 20 minutes, we’ll confirm scope, data availability, and whether a retrospective will produce a clean yes or no.