Jan 2021 | Get the latest from the best RBP advocates and auditors
Audit Spotlight
Cynthia Swanson, RN, CPC, CEMC, CHC, CPMA
Senior Audit Manager
Audit of hospital inpatient services results in a 89% plan savings
Case Scenario
The plan member was admitted to a hospital located in the state of Texas and had a one (1) day length of stay. The primary ICD-10-CM diagnosis reported on the insurance claim was M51.16, defined as, Intervertebral disc disorder with radiculopathy, lumbar region. The hospital submitted its services on a UB-04 claim form/electronic equivalent to insurance with total charges of $390,789.00.
In this case, high dollar charges included the operating room for $54,382.00, medical implants for $215,311.00, medical/surgical supplies for $87,630.76, anesthesia for $7,822.08, laboratory for $7,683.10 and pharmacy for $5,723.36. Other services included charges for recovery room, radiology, electrocardiogram, physical therapy, and occupational therapy. Read more...
Client Savings
Comprehensive line-by-line claim auditing by healthcare professionals is used to uncover errors typically not caught. ClaimDOC publishes a sample of five recent client savings audit results bi-monthly. See the savings below and know that together we can make healthcare affordable.
1. Dunbar, WV
Clinic dialysis for the treatment of end-stage renal disease
High-Dollar Services:
Three Dialysis Treatments: $22,888 Pharmacy: $12,709
Disclaimer – The analysis of any medical billing or coding is dependent on numerous facts, regulations, payer policies and codes, as well as the controlling plan description. The information contained herein is intended to provide a real-life example of opportunities for savings through ClaimDOC services but is not intended to provide medical, legal, or financial advice.
Member Experience
Feedback from a Member
I called my Member Advocate, Samantha, on a Friday in a panicked state upon learning that our insurance was changing. I had two hospital procedures scheduled and was completely confused as to how I should proceed to be sure I would be covered. I honestly never expected to get a return call on the same day and thought I would have a stressful weekend worrying about when I would speak to someone that could help me figure it all out. But a short time later I got a return call from Samantha. She is friendly, knowledgeable and most calming, patient, caring person I honestly have ever spoken to. She put my mind at ease by thoroughly explaining what her role was and what to expect from the insurance. What a huge relief! We have had a few phone calls since then and have texted each other when I have had questions and concerns and she has always promptly responded back in her very pleasant demeanor. I’m so grateful to Samantha and her great customer service!
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