DRG Downgrades

Take control of DRG downgrades. EnableComp’s advanced clinical and payer expertise delivers faster, defensible reimbursement.

How EnableComp conquers DRG Downgrade complexity

EnableComp breaks through DRG downgrade complexity bringing measurable improvement as we:

Strengthen documentation at the claim level to support accurate DRG assignment and prevent future downgrades.
Develop targeted, payer-specific appeals anchored in clinical evidence and built to stand up to payer scrutiny.
Leverage adaptive analytics within the e360 RCM® platform to detect patterns, pinpoint root causes, and guide course-adjusting action.
Accelerate reimbursement and reduce rework with workflows built to resolve downgrades efficiently and compliantly.

EnableComp’s DRG Downgrades solution, part of our Complex Denials Suite, delivers measurable impact on its own and results amplify when deployed along with our comprehensive denials solutions.

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Why choose EnableComp for DRG Downgrades

DRG downgrades demand a level of clinical precision and payer fluency that most hospitals cannot sustain on their own. Each case requires a deep understanding of coding rules, documentation standards, and payer behaviors that shift without warning.

EnableComp brings the expertise and intelligent technology needed to defend the correct DRG every time. Our dedicated specialists recode, validate, and advocate for accurate reimbursement, supported by insights surfaced across the millions of claims we’ve already processed.

With a purpose-built approach, we turn DRG downgrades into meaningful financial wins.

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Extensive experience with DRG resolution

Our DRG specialists bring deep experience to identify documentation gaps, recode complex cases, and advocate confidently for the most accurate DRG.

Payer-specific strategies that stand up to scrutiny

We tailor every DRG defense to the exact logic and behavior of each payer. This ensures appeals are clinically sound and designed to succeed.

Systemic insights that drive long-term improvement

Patterns revealed through our e360 RCM adaptive intelligence platform help pinpoint recurring documentation issues, service-line trends, and payer practices. These insights fuel the improvements that prevent future downgrades.

A structured feedback loop that strengthens future DRG documentation

Each case informs the next. Providers receive clear, actionable guidance on where documentation fell short and what changes will support the right DRG moving forward.

A dedicated parter that delivers strong reimbursement outcomes

We help hospitals achieve accurate reimbursement quickly and consistently. Clients see meaningful financial results: We’ve delivered tens of millions in DRG downgrade recoveries to providers in the past two years.

Three approaches EnableComp uses to resolve DRG downgrades

Defend the original DRG

We review the medical record for clinical, coding, and documentation support to justify the originally submitted DRG and secure appropriate reimbursement.

Elevate from the downgrade

If the original DRG lacks sufficient support, we identify documentation that justifies a higher-paying DRG than the one assigned by the payer.

Discover a better DRG

Our clinical and coding experts conduct a comprehensive review to uncover missed opportunities and identify a third, more accurate and higher-paying DRG than originally billed.

Our clients say it best

“The firm [EnableComp] is very professional, prompt, and proactive. When they identify a trend or an issue, they bring it to our attention immediately. Their reporting is very good and detailed. They are just outstanding all around. I can reach out to them and ask for a report, and they will promptly return that report.”

- RCM Analyst, KLAS Interview, July 2025

Transform results with the complete Complex Denials Suite

EnableComp’s DRG Downgrades solution delivers strong results on its own, and those gains multiply when providers entrust us with their broader denial challenges.

Our Complex Denials Suite focuses on the most complex denial categories, including DRG Downgrades, Medical Necessity, ED Downgrades, and Coordination of Benefits. We also bring deep expertise across the full spectrum of commercial denials.

Partnering with EnableComp for all denials delivers a unified, intelligence-driven strategy that reduces denials, improves recovery across claim types, and delivers stronger, more predictable financial outcomes.

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