The DOC

April 2023 | Get the latest from the best RBP advocates and auditors 

Industry Perspective

Brad Hansen

VP of Provider Relations

Buzzkill Part II: Health Care Quality Measures

Last month, I wrote a short article about healthcare pricing transparency and the opportunities and challenges presented by the newly available pricing data from hospitals and health plans. The article’s main message was that price transparency is a good thing, but it’s not without challenges.

This month, I’m focusing on the proliferation healthcare quality composite scores and report cards (usually in the form of a star ratings, grades, or provider rankings. For this article we’ll call them all “Composites”). Not surprisingly, my conclusion regarding the use of Composites parallels the use of pricing transparency data. Having information is a really good thing, but it must be used properly.

With that backdrop, let’s get to it.

Most of us have seen at least a few of the Composites such as CMS Hospital Compare Overall Star Ratings, U.S. News and World Reports Best Hospitals, or one of the many proprietary Composites from vendors peddling their own composite on a subscription basis. While these Composites have some differences, most are derived by complex, but well-tested analyses of utilization data, claims data, and/or hospital-reported outcomes data. These analyses get reduced to a single data point which, in theory, indicates whether or not high-quality health care has been provided, thereby predicting whether a patient can expect the same going forward.

This is where some of the problems with Composites begin. It’s not what they are but how they get used (or misused). To understand this, we must consider (1) the types of underlying quality measures used to develop the Composites, (2) the sources and limitations of the data used to develop Composites, and finally (3) how we use the Composites. Read more...

Audit Spotlight

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

Senior Audit Manager

IV Acetaminophen Was Not Administered– Why Did It Show Up on the Billed Charges?

In this Claims Audit Spotlight, we focus on not only egregious charges billed by the hospital for Intravenous (IV) Acetaminophen, but the medication was also not supported as ordered by a practitioner and administered to the patient based on medical record documentation.  

A hospital located in Ohio billed for outpatient hospital services provided to a child having the primary diagnosis of esotropia, a form of strabismus in which one or both eyes turn inward. Corrective surgery was performed on the child’s right eye.

ClaimDOC auditor’s analysis of the hospital claim raised questions noting the egregious charge for the medication of IV Acetaminophen and if that amount of IV Acetaminophen billed (totaling 33,000 mg for a one day stay) was given to the child. Patient medical records were requested to verify the claim information reported/billed. 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. Martinsville, VA

Outpatient dialysis clinic services for the treatment of end stage renal disease

High-Dollar Services:

• Dialysis Treatments (13): $109,226
  
  

Savings Summary:

Billed Charges: $109,226
ClaimDOC Allowed: $4,555.59
Plan Savings: $104,670.41
Reduction: 96%

2. Scottsdale, AZ

ASC services for the treatment of rotator cuff repair right shoulder and related surgery

High-Dollar Services:

Surgery: $113,724

Savings Summary:

Billed Charges: $113,724
ClaimDOC Allowed: $6,685.15
Plan Savings: $107,038.85
Reduction: 94%

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

"Sharla helped me from beginning to end. She made sure my provider understood everything. When I went to my appointment, there was no delay. Sharla is a great person to have, representing your company and me. I feel like I'm in good hands. Thanks again, Sharla!"
 

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