The DOC

Nov 2020 | Get the latest from the best RBP advocates and auditors 

Audit Spotlight

Cynthia Swanson, RN, CPC, CEMC, CHC, CPMA

Senior Audit Manager

Audit of outpatient procedure results in a 99% plan savings

Case Scenario

The member received a trigger point injection procedure which was performed in an outpatient ambulatory surgical center (ASC) for the relief of muscle and low back pain. The physician performing the service submitted their CMS-1500 claim to insurance which totaled $12,806.00. The primary ICD-10-CM diagnosis reported on the claim was M79.18 – Myalgia, other site (muscle pain).

In this case, two procedure codes were reported/billed on the claim, CPT code 20553, defined as, trigger point injection (TPI), and CPT code 76942 defined as, ultrasound guidance for needle placement or biopsy. High dollar charges included $10,794.00 for the TPI and $2,012.00 for the ultrasound needle guidance. 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. Urbana, IL

Nine-day hospital stay for the treatment of myasthenia gravis

High-Dollar Services:

Pharmacy: $47,967.00
Room and Board: $32,130.00
Treatment/Observation Room: $27,600.00

Savings Summary:

Billed Charges: $135,372.52
ClaimDOC Allowed: $26,633.73
Plan Savings: $108,738.79
Reduction: 80%

2. Rogers, AR

Three-day hospital stay for the treatment of heart attack

High-Dollar Services:

Cardiac Cath Lab: $34,109.00
Room and Board: $11,679.00

Savings Summary:

Billed Charges: $62,940.37
ClaimDOC Allowed: $16,543.06
Plan Savings: $46,397.31
Reduction: 74%

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 just wanted to take a moment to relay to you what an outstanding job my Member Advocate, Seth, has done assisting my husband and I. He has gone above and beyond to provide stellar customer service and displays a work ethic you don’t see too often these days. We are very appreciative we are able to work with him when we call.

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