April 2022 | Get the latest from the best RBP advocates and auditors
Industry Perspective
Stephanie Mohr
Senior Relationship Manager
DPC & RBP- Because it works
For those in the benefits world, you know the acronyms. DPC – direct primary care and RBP – reference based pricing. The former is a method to pay for your doctor the same way you pay for a gym membership. It’s a subscription-based program not tethered to an insurance program since the individual or the employer is buying a membership to get physician access rather than using a traditional insurance network. This model has been marketed as a concierge physician service for the upper class in the past, but is quickly gaining traction with employer-sponsored health plans. RBP is a pricing tool and a method self-funded employers use to help control claims cost and ultimately create a more sustainable health plan long term. Both services are highly innovative on their own, so what happens when you put the two together? We’ll explore.
Steerage
Benefits consultants know member steerage, when done effectively, can create tremendous value for clinical and financial outcomes. That’s why there’s been a massive influx in health care consumer tools to measure provider quality and cost. The utilization of those tools varies drastically from group to group depending on factors such as communication strategy, employer support, group demographics, provider landscape in a given geography, user experience of the tool, etc. Read More...
Audit Spotlight
Cynthia Swanson, RN, CPC, CEMC, CHC, CPMA
Senior Audit Manager
Freestanding Emergency Departments vs Urgent Care Clinics
Both types of facilities accept most types of insurance and cash payments. The Centers for Medicare and Medicaid (CMS) does not recognize or reimburse freestanding emergency departments. (Exception for licensed independent freestanding emergency departments choosing to enroll as a hospital during the COVID-19 public health emergency (PHE). State legislation and regulation for freestanding emergency departments change frequently with either no legislation or provisions for freestanding emergency departments in states with significant legislation (for example, Texas, Colorado). Many states do not have specific regulations for urgent care clinics – the rules that apply to opening a medical office, such as medical licenses, business licenses, and registration of x-ray/lab equipment, are applicable. Other states do have regulations specific to urgent care clinics.
Case 1
A 12-year-old male plan member was seen in a freestanding emergency clinic in Texas for the diagnosis of acute pharyngitis.
UB-04 claim form/electronic equivalent was billed for the following services: CPT code 99283 – level three ER visit – $9,656, CPT code 94760 – measurement of blood oxygen level – $644.28, HCPCS code A4670 – blood pressure monitor – $78.32
Total freestanding emergency department charges $10,378.60 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. Sarasota, FL
Outpatient ASC services for the treatment of osteoarthritis of left hip and related surgery.
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
My member advocate Lachelle has been so helpful to me! I had an issue with a claim and explained the problem to her. It can be a nightmare being bounced around, but Lachelle didn't do that. She was thorough and calm. Lachelle took charge and got the issue resolved. She was literally my savior! I am SO glad to have ClaimDOC as part of my health plan.
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