The DOC

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

Industry Perspective

Jim Wilson

Human Resources Liaison

Be a Leader, Protect Member Money

If your company is struggling with the ever-increasing cost of healthcare for your workforce, you must understand that there is no end to it. Changing medical carriers will not make a meaningful difference. No one is coming to ease the burden. Your traditional PPO costs are not going to go down at the next renewal, or the renewal after that or even the next renewal after that. This is not a sustainable model for American workers.

As a former human resources leader, I want to highlight an element of reference-based pricing that doesn’t get discussed nearly enough — members’ money. RBP gets so much attention for the savings realized by employers. Often overlooked is the savings shared by employees enrolled in RBP plans. 

Before joining ClaimDOC, I implemented RBP with ClaimDOC at my former company. I didn’t realize it at the time, but being a champion of RBP was an unusual role for HR to play. More commonly, this sort of project is at least initiated by an executive, such as a CEO or CFO, who becomes intrigued by the advertised savings opportunities for employers. It was clear the 25-30% employer savings was going to happen. As the leader of the project within my former employer, I was excited to tangibly contribute to the bottom line. Read more...

Audit Spotlight

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

Senior Audit Manager

High-Cost Cancer/Other Drugs and the Mystery of Hospital Markups

In this Claims Audit Spotlight, we focus on high-cost cancer/other drugs and their related charges reported/billed by hospitals. High-cost cancer/other drug prices and their frequency of use are a growing trend in cancer care and are affecting patient care and our health system.

As healthcare costs continue to climb an upward slope, an escalated need exists for closer analysis of healthcare claims to identify egregious charges, improper medical coding, and billing errors and associated improper claim payments.

Hospital Outpatient Services — High-Cost Cancer/Other Drugs and Related Charges

Claim Example One

A 41-year-old female patient received outpatient chemotherapy services for the treatment of right breast cancer at a Georgia hospital on two dates of service.

The hospital reported/billed HCPCS code J9317 (Trodelvy® — 546 units) and related charge of $85,176.00. The reported hospital cost for the drug J9317 (these units) — $10,724.08.

The hospital also reported/billed HCPCS code J2506 (Pegfilgrastim — 24 units) — charge of $71,628.00. The reported hospital cost for J2506 (these units) — $9,018.32. Read more...

DirectAccess+ Savings

With 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. Utilizing the median commercially contracted price gives a fair estimate on the true savings being generated for the plan and the member. Licensed healthcare professionals conduct comprehensive line-by-line claim auditing to uncover errors typically not caught. Following are five recent audit results showcasing substantial savings.

1. Spartanburg, South Carolina

Six-day hospital stay for the treatment of pneumothorax and related surgery.

High-Dollar Services

• Operating Room: $41,361.10

Traditional Network Plan

• Hospital Bill: $67,841.42
• Median Commercially Contracted Price
  • $41,257
• Patient Responsibility 20% Coinsurance:
  • $8,251.40

DirectAccess+™

• Hospital Bill: $67,841.42
• ClaimDOC Allowable
  • $16,641.86
• Patient Responsibility 20% Coinsurance:
  • $3,328.37
• Plan Savings: $24,615.14
• Member Savings: $4,923.03

2. Houston, Texas

Seven-day hospital stay for the treatment of sepsis, diabetes and cellulitis (right leg).

High-Dollar Services

• Pharmacy: $35,859

Traditional Network Plan

• Hospital Bill: $101,623.50
• Median Commercially Contracted Price
  • $28,901
• Patient Responsibility 20% Coinsurance:
  • $5,780.20

DirectAccess+™

• Hospital Bill: $101,623.50
• ClaimDOC Pricing:
  • $20,643.14
• Patient Responsibility 20% Coinsurance:
  • $4,128.63
• Plan Savings: $8,257.86
• Member Savings: $1,651.57

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

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