The DOC

Sept. 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 medical claim identifies hospital error in reported/billed medical professional services

Case Scenario

Outlined below is a claim example where the ClaimDOC audit team identified the hospital incorrectly reported/billed medical professional services on the inpatient hospital claim.

A Maine hospital submitted its hospital inpatient claim and related charges to insurance with total charges of $140,894.58. The inpatient hospital services included a five-day stay for the treatment of coronary artery disease with occlusion and stenosis of the left carotid artery. High dollar charges included operating room for $46,724.00 and room and board for $20,910.00.

During our analysis of the hospital claim and hospital itemized bill, we identified the incorrect hospital billing of professional general fees for $20,477.00 and professional anesthesia fees for $6,437.00, totaling $26,914.00. These professional fees should not be reported and billed on the acute care hospital UB-04 claim, rather they should be reported and billed on the CMS-1500 claim form. 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. Los Angeles, CA

Hospital outpatient services for the treatment of appendicitis with perforation and related surgery

High-Dollar Services:

Operating Room: $30,607
CT Scan: $29,673
Emergency Room: $9,427

Savings Summary:

Billed Charges: $99,787
ClaimDOC Allowed: $7,976.14
Plan Savings: $91,810.86
Reduction: 92%

2. Manhasset, NY

Hospital outpatient services for the treatment of ventral hernia and related surgery

High-Dollar Services:

Operating Room: $40,205
Anesthesia: $7,010

Savings Summary:

Billed Charges: $59,909
ClaimDOC Allowed: $8,779.77
Plan Savings:$51,129.23
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 have reached out to my Member Advocate Dallas several times to help me with services and coverage. He has an amazing personality and work ethic. Whenever I need him to help me, he always keeps on top of the situation and comes through. I am glad to have someone like Dallas on my side!

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