The DOC

March 2022 | Get the latest from the best RBP advocates and auditors 

Industry Perspective

Brad Hansen

VP of Provider Relations

Provider Relations Unicorn

Prior to joining ClaimDOC in May of 2021, I spent most of the last 25 years negotiating transactions on behalf of health systems, hospitals and physician practices. These transactions covered all corners of healthcare including provider reimbursement, physician employment, joint ventures and healthcare mergers (all Stark and Anti-Kickback compliant, of course!). Like most in the healthcare administration and legal circles, the body of work ranges from very successful to complete duds.

I’d like to think my success rate was much higher than even the best MLB batting averages, but like most healthcare administrators and lawyers, I probably learned more from the losses than the successes. One lesson etched from both the wins and the losses is that we must understand the value proposition we bring to the table. Knowing the value proposition is key to understanding leverage of yourself as well as other partners at the table. It also helps anticipate which are the good deals and which are the duds.

At ClaimDOC, the value proposition is very clear. It’s strategic plan management and effective relationships with members, clients, brokers and yes, even providers. My question when ClaimDOC hired me was the same that many of our broker partners ask: How does an RBP-based company, focused on staunchly defending their allowable, cultivate strong relationships with providers and create a smooth access experience without relying on contracts? Read More...

Audit Spotlight

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

Senior Audit Manager

Audits uncover extreme cost variation in hip replacement surgeries

The case scenarios outlined below provide an overview of two individuals having a total hip replacement procedure (also called total hip arthroplasty) reported/billed by each hospital with CPT code 27130. Typical surgical procedure time is 1-2 hours, where the surgeon removes damaged cartilage/bone and then positions a new metal, plastic, or ceramic implants to restore alignment and function of the hip.

Case One

Member underwent hospital outpatient surgery for a left total hip replacement (CPT procedure code 27130) at a hospital located in San Diego, CA.

The hospital submitted its facility claim to insurance with total charges of $201,072.72.

High dollar charges included:

• Operating room for $96,403
• Implants for $79,466.75
• Anesthesia for $8,273
• Recovery room for $6,312

Below is a summary of the hospital facility charges billed, related ClaimDOC pricing and savings 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. Bridgeport, CT

Assistant surgeon services for the treatment of breast cancer and related surgery

High-Dollar Services:

Assistant Surgeon Services: $80,640

Savings Summary:

Billed Charges: $80,640
ClaimDOC Allowed: $237
Plan Savings: $80,403
Reduction: 99%

2. San Ramon, CA

Ambulatory Surgical Center services for the treatment of medial meniscus tear, left knee

High-Dollar Services:

Ambulatory Surgery Center Services: $60,600

Savings Summary:

Billed Charges: $60,600
ClaimDOC Allowed: $2,319.04
Plan Savings: $58,280.96
Reduction: 96%

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 Allyson makes my life easier. I submitted a provider nomination form, and she went the extra mile. She not only completed Pave the Way™ with the hospital I selected, but she also completed Pave the Way™ with several other providers and labs the hospital works with frequently to make sure everything was ready to go for my procedure, even though I forgot to share the additional information. By the time I remembered, she already had everything done. I can't thank her enough. 

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