The DOC

Oct. 2021 | Get the latest from the best RBP advocates and auditors 

Audit Spotlight

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

Senior Audit Manager

Audits uncover coding and billing errors related to physician/practitioner services

Pricing and payments for professional services are commonly based on a physician fee schedule. Medicare’s physician fee schedule provides information for more than 10,000 physician services, the associated relative value units (RVUs), a fee schedule status indicator, and various payment policy indicators needed for applicable payment adjustment.

Case Scenario

Member was seen in an office setting by a nurse practitioner located in the state of Georgia for the diagnosis of muscle strain in the abdomen due to overexertion.

The nurse practitioner reported/billed an office visit using CPT code 99203. This code is defined as:

“Office visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of the total time is spent on the date of the encounter”.

As part of our claims analysis, ClaimDOC uses up-to-date benchmark data/tools to determine the range of practitioner charges by practice locality. 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. Blacksburg, VA

Hospital outpatient services for the treatment of uterine fibroids

High-Dollar Services:

Operating Room: $55,865
Medical/Surgical Supplies: $25,692
Anesthesia: $8,868

Savings Summary:

Billed Charges: $101,918
ClaimDOC Allowed: $10,189.91
Plan Savings: $91,728.09
Reduction: 90%

2. New Albany, OH

Ambulatory surgery center services for the treatment of right knee osteoarthritis

High-Dollar Services:

Surgery: $97,786.30

Savings Summary:

Billed Charges: $97,786.30
ClaimDOC Allowed: $10,864.64
Plan Savings: $86,921.66
Reduction: 88%

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've been in Human Resources for years and have never had someone assist me with managing my insurance plan, especially not to the extreme that Levi has. It's absolutely outstanding! I am truly thankful to have Levi as my Member Advocate. He goes above and beyond to ensure I am taken care of.

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