The DOC

March 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 outpatient laparoscopic hysterectomy results in 78% plan savings

Case Scenario

Member underwent outpatient surgery for a laparoscopic hysterectomy at a medical center located in Georgia.

The hospital submitted their facility claim to insurance with total charges of $61,211.92. Our analysis of the claim resulted in questionable billing related to a pharmacy charge and the quantity of units reported for HCPCS code C9290, defined as, injection, bupivacaine liposome, 1 mg. Medical records were requested to verify the billed charges. Based on our review of practitioner documentation, we identified the billed charges of $25,199.68 for 532 units should have alternately been reported as billed charges of $6,299.92 for 133 units, a pharmacy overcharge of $18,899.76.  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. Salem, VA

Hospital outpatient services for the treatment of enlarged ovarian cyst

High-Dollar Services:

Medical/Surgical Supplies: $28,653.00
Operating Room: $26,930.00

Savings Summary:

Billed Charges: $74,391.00
ClaimDOC Allowed: $7,423.77
Plan Savings: $66,967.23
Reduction: 90%

2. Okeechobee, FL

Five-day hospital stay for the treatment of diverticulitis of the intestine

High-Dollar Services:

Operating Room: $31,916.00
Medical/Surgical Supplies: $24,704.38
Room and Board: $13,618.00
Pharmacy: $13,606.00

Savings Summary:

Billed Charges: $107,735.68
ClaimDOC Allowed: $15,814.81
Plan Savings: $91,920.87
Reduction: 85%

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 want everyone to know how amazing my member advocate Brandi is. She is not only a knowledgeable professional with a calm demeanor, but funny and very personable. I can't fully explain what a relief it is to have someone like Brandi by your side while dealing with medical bills.

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