Higher-Weighted Diagnosis Related Group Reviews

Overview

Beginning in September 2025, Acentra Health will conduct Higher-Weighted Diagnosis-Related Group (HWDRG) Reviews on behalf of the Centers for Medicare & Medicaid Services (CMS) as part of the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) program.

These post-payment reviews assess the accuracy of inpatient hospital claims that have been adjusted to a higher-weighted DRG following initial payment. The goal is to ensure that claims accurately reflect coding and medical necessity, thereby safeguarding both the Medicare program’s integrity and beneficiary trust.

Review Details

An HWDRG review is initiated when an inpatient hospital claim is resubmitted for additional reimbursement due to coding changes. These changes are typically due to the addition of complications, comorbidities, or procedures that shift the claim into a more resource-intensive DRG.

Two Key Components of the Review

DRG Validation

Certified coding professionals review patient records to ensure that submitted codes are accurate, complete, and fully supported by the medical documentation. All reviews follow ICD-10-CM/PCS coding guidelines and official coding references.

When clinical input is needed to validate coding decisions, board-certified, actively practicing independent physician reviewers are engaged to provide expert review and confirmation.

Medical Necessity Review

All medical records undergo an initial screening to identify potential concerns with medical necessity. Records that do not pass this screening are then referred to board-certified, actively practicing independent physician reviewers for review.

These physicians evaluate the medical record to determine whether the inpatient admission and services were medically necessary, using national coverage guidelines and CMS criteria.

Who is Subject to Review?

Hospitals that submit adjusted claims leading to higher-weighted DRGs may be selected for review. Selection is based on CMS’s audit protocols and national data analytics.

In the near future, Acentra Health will be requesting medical records, so your QIO Liaison or Medical Records contact is needed, to avoid potential non-payment denials for lack of medical records.

Please ensure that your contact information is up to date for medical record requests. A new Memorandum of Agreement (MOA) is not required.

For questions or more information, email QIOCommunications@acentra.com. For regions reviewed by Commence Health (Livanta), visit www.commencehealthqio.cms.gov.

HWDRG Review Process

Please note: Communications from Acentra Health will be sent by fax when possible or by U.S. mail if fax is not available.

• Acentra Health expects to send the first medical record requests to the appropriate points of contact soon.
• Records must be submitted electronically. Click on the button in the right column to be directed to the medical record upload page. 
• Before making any corrections affecting DRG assignment or medical necessity, the hospital will be provided with an opportunity for discussion.
• If the hospital does not respond to the opportunity for discussion, the initial findings will be made final. The Medicare Administrative Contractor (MAC) will be notified of the change for claim adjustment.
• If the change involves denial of an inpatient admission, the Medicare beneficiary will also be notified.
• If the hospital responds to the opportunity for discussion, the response is taken into consideration by Acentra Health when making the final determination on the claim.
• Hospital samples will consist of claims reviewed within a rolling period, and a summary report with all review findings will be issued for educational purposes.
• An educational one-to-one teleconference will be scheduled with the hospital when results from a provider sample indicate a need for education.

Understanding HWDRG Reviews

For providers seeking to better understand the policies and procedures that inform HWDRG reviews, Chapter 4 of the QIO Manual outlines the official processes BFCC-QIOs follow when conducting case reviews, including DRG validation and medical necessity assessments. It serves as the most direct reference for how Acentra Health conducts HWDRG reviews on behalf of CMS.

Download the QIO Manual: Chapter 4 (PDF)