AI AGENTs
DRG AGent
Smarter and faster
DRG decisions, built
on complete clinical context
Move beyond rules-based coding audits
Alaffia’s DRG Agent reads the full clinical record, reasons against your plan’s policies and coding guidelines, and surfaces only the cases with real opportunity, while clinicians stay in control.
SUPERCHARGED DRG REVIEW
DRG errors hide in the clinical narrative, not just the codes
Traditional DRG audit tools flag coding patterns without understanding the clinical context behind them. Most only catch what's missed before or after payment, never both. Alaffia’s DRG Agent reads the complete medical record instead and uses your DRG policies to identify opportunities within the documentation details, before submission and after adjudication.
Clinical context, not just codes
Our Agent weighs lab values, physician documentation, and clinical criteria together, the same way an experienced reviewer would.
Smart triage
Routine cases clear automatically, so clinicians only spend their time on cases with a real DRG change opportunity, not a flooded queue.
Cut wasted spend
Build DRG review capability directly into your operation and capture more of the savings that manual review alone would miss.
The sepsis DRG challenge, solved in minutes, not hours
Sepsis carries some of the highest DRG risk in inpatient claims, since severity level miscoding is a common driver of both overpayment and underpayment. Our DRG Agent reviews every sepsis case against clinical documentation and coding guidelines to surface the opportunity that a rules engine, or an overloaded review queue, is likely to miss.
10-15 min
per review
down from 1+ hour
20x
increase in throughput
70%+
of routine approvals
automated
$9,300
average dollar savings
per DRG change
The clinical decisioning layer behind every DRG recommendation
DRG Agent
From data extraction to clinician sign off, Alaffia’s DRG Agent automates smart triage, surfaces more savings, and cuts the administrative burden of manual DRG review, while keeping humans at the helm.
Alaffia’s DRG Agent is configured to your reimbursement policies, coding requirements, local laws, clinical criteria, and payment rules.
The automation framework is configurable by DRG code, so it can be tailored to how your team wants each condition reviewed.
Working from your clinical configuration, the Agent cross references the normalized medical record against your DRG criteria and policy guidelines, weighing lab values, physician documentation, and clinical criteria together the way an experienced reviewer would, not just matching coding patterns.
Every recommendation includes a clear clinical rationale and traceable citations, with links back to the original medical record and policy documents for verification.
Human clinicians are always at the helm for overview and signoff.
Comprehensive inpatient records (even scanned PDFs) are normalized into structured clinical facts through a clinician-build automated process.
Before your team looks at it, the DRG driving diagnoses are mapped to the relevant documentation within the exhaustive record.
Claims are ranked by savings opportunity and clinical complexity, so reviewers clear straightforward cases quickly and spend their time where it matters most.
Case study
How Alaffia prevented a $19K neurologic DRG upcode through AI clinical validation
See how Alaffia found that four diagnoses coded on an inpatient admission weren't clinically supported, leading to a DRG reassignment that returned more than $19,000 to a health plan.
returned to the health plan on a single inpatient admission
unsupported diagnoses
clinically invalidated
on a single inpatient claim review
Fit our AI solutions into how your team already works
Insource
Your clinical team, accelerated.
Put our DRG Agent to work inside your existing workflows. Your coders and clinicians handle more DRG reviews, more consistently, without adding headcount.
Hybrid
Your team, plus ours.
Combine your in-house reviewers with Alaffia's clinical experts to expand DRG review capacity without sacrificing accuracy.
Outsource
Your claims, our team.
No DRG review staff to spare? Alaffia's clinical team handles DRG validation end to end, powered by the same platform.
Get in touch with a member of our team today to explore which solution is right for you.
Enterprise-level security
We uphold the strictest enterprise-grade security standards to keep member and payer data private and secure.
Frequently asked questions
Alaffia’s DRG Agent currently supports all DRGs.
Building alongside your team, we configure the Agent around your plan's specific DRG policies, coding guidelines, and decision criteria. It mimics your audit process and follows your decision tree on the way to each recommendation.
No. DRG findings are designed to reduce friction, not add to it. Every recommendation carries a clinical rationale and traceable citation back to the record, so your team can have a defensible, evidence based conversation with providers instead of a disputed one.
Alaffia continuously monitors DRG grouper updates and coding guideline changes as they're released, so your configuration stays current without manual upkeep on your end. Same with clinical guidelines; as new norms surface, Alaffia’s clinical team will work with your team to incorporate them.
Turn more DRG reviews into recovered savings
Discover how Alaffia’s DRG Agent finds opportunity your rules engine misses.
Learn more