The DOC

April 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 treatment of malignant melanoma results in plan savings

Case Scenario

Member underwent treatment in a New Hampshire hospital outpatient department for the treatment of malignant melanoma. The hospital submitted their claim to insurance with total charges of $65,890.48.

Our analysis of the claim identified charges for pharmacy was $64,154.48. The pharmacy (medication) was reported/billed with HCPCS code J9271, defined as, Injection, pembrolizumab, 1 mg. (KEYTRUDA) with reported quantity units of 200.

Based on information published on the Keytruda.com website, the list price for each indicated dose of KEYTRUDA when given every 3 weeks is $9,869.94. 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. Port Charlotte, FL

Hospital outpatient services for the treatment of left knee osteoarthritis

High-Dollar Services:

Implants: $111,421.74
Operating Room: $75,132.79
Anesthesia: $13,756.19
Recovery Room: $11,688.80

Savings Summary:

Billed Charges: $237,308.23
ClaimDOC Allowed: $18,213.45
Plan Savings: $219,094.78
Reduction: 92%

2. Cincinnati, OH

Eight-day hospital stay for the treatment of COVID-19 and respiratory failure

High-Dollar Services:

Room and Board: $37,106.16
Medical/Surgical Supplies: $14,768.67
Respiratory Services: $12,414.67

Savings Summary:

Billed Charges: $93,730.02
ClaimDOC Allowed: $15,200.00
Plan Savings: $78,530.02
Reduction: 84%

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

Dealing with medical bills can be petrifying and frustrating until you get a ClaimDOC Member Advocate like Tabitha on the phone. Not only was she very professional and knowledgeable, she also patiently answered all my questions and put my mind at ease explaining the process and offering to further assist me if needed. She goes above and beyond and deserves a huge thank you!

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