The DOC

September 2024 | Get the latest from the best RBP advocates and auditors 

Industry Perspective

Danielle Young

Vice President of Business Development

The RBP Buying Conversation: It’s Not Apples-to-Apples

When I worked as a broker, I always believed that modest and selective diversification of carrier partners was important. For each line of benefits coverage I recommended or placed, I would have two or three options, but I didn’t do business with everybody. From my perspective, being both knowledgeable and discerning were important parts of my consultative relationship with my clients.

I would have a few good voluntary carrier partners, major medical fully insured carriers, stop-loss partners, level-funded products, TPAs, etc. This helped me compare options — often apples-to-apples — to my clients and make recommendations. The broker/consultant community has historically trained buyers to compare products in this way.  Read more...

Audit Spotlight

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

Senior Audit Manager

Validated — Double Billing on Healthcare Claims is Real

In this Audit Spotlight, we focus on due diligence — closely reviewing claims and keeping in mind double-billing on healthcare claims is real.

Double-billing occurs when a provider attempts to bill Medicare/Medicaid and either a private insurance company or the patient for the same service/treatment, or when two providers attempt to get reimbursed for services rendered to the same patient for the same procedure on the same date of service. If double-billing is intentional, then it is a form of fraud. The Office of Inspector General has expressed concerns about double-billing and other abusive billing practices for several years. While detailed percentages of double-billing are not always publicized, the OIG, Medicare, Medicaid, health plans and numerous other groups/organizations have consistently highlighted the associated risks of double-billing. Read more...

DirectAccess+ Savings

DirectAccess+™ clients and members achieve maximum protection and savings. To establish savings information, ClaimDOC analyzes commercial contract pricing from data disclosed by hospitals and health plans. The audit team performs line-by-line claim audits to help clients and members maximize their savings. Below is one recent audit result showcasing substantial savings.

1. Spartanburg, South Carolina

Eleven-day hospital stay for the treatment of heart attack and related procedures

Traditional Network Plan

• Hospital Bill: $304,489.61
• Median Commercially Contracted Price
  •  $137,778.61

• Patient Responsibility 20% Coinsurance:
  • $27,555.72

DirectAccess+

• Hospital Bill: $304,489.61
• ClaimDOC Allowable
  • $67,545.22

• Patient Responsibility 20% Coinsurance:
  • $13,509.04

• Plan Savings: $70,233.39
• Member Savings: $14,046.68

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.

Broker Experience

Feedback from a Broker

"I’ve been in the benefits world for 16+ years now. I’ve come across a lot of service representatives from carriers and other entities. When I tell you that Heidi is by far the best I have ever worked with, it means something. It makes it easy to tell my colleagues when considering reference-based pricing carriers, that we go directly to y’all because of Heidi."

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