Feb. 2022 | Get the latest from the best RBP advocates and auditors
Industry Perspective
Omar Arif
Senior Vice President of Growth
RBP Takeovers
Reference based (RBP) pricing is making its way to the forefront of conversations between employers and their benefits consultant. Opinions vary drastically on whether or not RBP can be an effective and sustainable long-term strategy for an employer-sponsored health plan. It’s widely known that RBP plans can save money, but hesitancy comes from a number of unknowns about: customer service, balance bills, denial of services from a healthcare provider, collections or credit impairments, or even litigation against a plan member. Picking the right vendor is crucial and it can be hard to delineate the meaningful differences and know what you are buying. It doesn’t help that despite the very clear differences in models we are all lumped together as RBP. The broker gets put in a tough position of having to take vendors at their word for what they will deliver.
Fool Me Once More than ever, we are seeing consultants separating their belief in RBP from the failures of an RBP vendor. They buy into resisting the waste and abuse that takes place in the current network system and know RBP is the most impactful and sustainable way to bend the curve. They recognize when the vendor they selected is failing and needs to be replaced instead of scrapping the entire strategy.
I recently helped move a group from a bad situation where the consultant did an excellent job putting all the pieces together for success. They brought in a transparent PBM, a solid TPA, and even layered in a direct primary care system with some creative plan design. It all started crashing because the discount RBP vendor could not deliver on their service. The consultant didn’t blink, they made a change to bring in another PEPM RBP vendor only to see them perform equally as bad. They had just blown through two of the more prominent PEPM players in the market….now what. Read More...
Audit Spotlight
Cynthia Swanson, RN, CPC, CEMC, CHC, CPMA
Senior Audit Manager
Hospital Bills Vary for Treatment of COVID-19, Including Charges for Veklury® (Remdesivir)
In this Audit Spotlight, we focus on four case scenarios with hospital-related charges for complex hospitalizations related to COVID-19 that require ventilation and/or admission to the intensive care unit (ICU) and noncomplex hospitalizations.
Hospital charges for COVID-19 hospitalizations vary extensively, depending on insurance, length of stay, severity, the number of diagnoses/conditions, treatments received, and the location/state where care is provided.
Case 1 A 51-year-old plan member was admitted to a hospital in Wisconsin and had a nine-day inpatient stay. The primary ICD-10-CM diagnosis reported on the claim was U07.1, COVID-19. Additional diagnoses included pneumonia due to COVID-19, acute respiratory distress syndrome, obesity, and hypertension. The hospital submitted its services on a UB-04 claim form/electronic equivalent to insurance with total charges of $105,789.25.
High dollar charges included pharmacy for $58,449.75 and room and board for $21,207. The pharmacy charge for each Remdesivir 100 mg, injectable – $3,770.
Review of the hospital itemized bill identified unbundling of services part/partial to other reported/billed services. 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. Hazel Park, MI
Outpatient dialysis services for the treatment of end-stage renal disease
High-Dollar Services:
Dialysis Treatments (10): $118,103.27
Savings Summary:
Billed Charges: $118,103.27 ClaimDOC Allowed: $3,709.95 Plan Savings:$114,393.32 Reduction: 97%
2. Plant City, FL
Hospital outpatient services for the treatment of hammertoes, right foot, 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 made a last-minute appointment with a new provider. I immediately filled out a provider nomination request online, but it was only two days before my appointment. My Member Advocate Maria took ownership of my request and coordinated with the provider within one business day. I was very happy that I was able to go to this appointment with no concerns, knowing that the provider would accept my insurance, understood the plan, and the claim will be handled. Thank you, Maria!
We've updated our website!
Whether you're an Employer, Provider, Broker, Stop Loss Carrier, or Member, get valuable information 24/7 by visiting www.claim-doc.com.
You received this email because you signed up on our website or made a purchase.
ClaimDOC, 3200 Westown Parkway, West Des Moines, IA 50266, 1-888-330-7295
.png?upscale=true&width=200&upscale=true&name=Audit%20Spotlight%20(1).png)
