June 2022 | Get the latest from the best RBP advocates and auditors
Industry Perspective
Stuart Miller, J.D.
Associate Counsel
Historic $1 Million Fine – What to Know
What is the best way to enforce regulations in an already heavily regulated industry like healthcare? Is it the carrot a la non-profit tax breaks and government subsidies or is the stick the better option? We are about to find out. The Centers for Medicare and Medicaid Services (CMS) has long been the enforcer of penalties for healthcare’s bad actors when it comes to Medicare/Medicaid noncompliance. The same is supposed to be true for price transparency. However, until very recently, CMS has never issued a single civil monetary penalty against a healthcare provider for noncompliance with federal price transparency requirements.
On June 7, 2022, this changed and a (relatively) modest civil monetary penalty was levied against Atlanta-based Northside Hospital. The total fine for the two facilities (Atlanta and Cherokee) slightly exceeded $1 million ($883,180 and $214,320 respectively). Read More...
Audit Spotlight
Cynthia Swanson, RN, CPC, CEMC, CHC, CPMA
Senior Audit Manager
Red Flags Raise Questions: Egregious Charges or Billing Errors?
In this Claims Audit Spotlight, we focus on two recent claims where the auditor’s eyes did a double-take, red flags went up and the question was asked – is the practitioner really charging this much for their service or is this a billing error?
Case Scenario 1
A 56-year-old plan member was seen in a Georgia ambulatory surgical center (ASC) setting for a screening colonoscopy test.
Case Scenario 2
A 15-year-old plan member was seen in a Texas hospital outpatient setting for the treatment of a sprain of anterior cruciate ligament and lateral meniscus tear of the right knee and related surgery. 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. Tampa, FL
Hospital outpatient services for the treatment of benign tumor of parathyroid gland and 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
I have to start my day by letting you know what a great advocate Sharla is! She has a great personality and her follow-up with my provider nominations is on point all of the time. This one is a keeper in my book and ClaimDOC is fortunate to have someone like her working for the organization.
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