February 2024 | Get the latest from the best RBP advocates and auditors
Industry Perspective
Amy Howells, J.D.
Associate Counsel
Champagne for my Real Friends, Real Pain for my Sham Friends: Proposed Class Action Lawsuit Puts Spotlight on Fiduciary Duty under ERISA
In early February of this year, a proposed class action lawsuit was filed against the company Johnson & Johnson and their Pension & Benefits Committee, sounding an alarm to those in the self-funded health plan industry. The complaint, brought by Johnson & Johnson employee Ann Lewandowski, individually and on behalf of other similarly situated employees, alleges Johnson & Johnson violated the Employee Retirement Income Security Act (ERISA), in particular, by breaching its fiduciary duty in the form of mismanagement of Johnson & Johnson’s prescription-drug benefits plan through their contracted Pharmacy Benefits Manager (PBM). Although in the early stages of litigation, this suit will likely serve as a clarion call for employers to take a harder look at what they’re paying for.
Hospital outpatient care examples may include receiving, x-rays, CT scans, MRIs, PET scans, laboratory tests, colonoscopies, mammograms, chemotherapy infusions, radiation treatments, same day surgery, emergency room (ER) visits, observation care/services, and others.
Hospital inpatient care examples may include hospital admission for a major/complex surgery, serious illness or medical diagnosis, childbirth, behavioral health rehab, severe injuries, and others.
The actual location where observation care services are provided in the facility does not define whether a patient is inpatient or outpatient. It is the practitioner’s written order(s) and the duration of stay that determines whether hospital care is designated as outpatient or inpatient status.
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. Plano, TX
Freestanding ER services for the treatment of hematuria and kidney stone
High-Dollar Services:
Emergency Room: $17,098.55
Observation (3 hours): $16,222.50
Savings Summary:
Billed Charges: $61,922.39 ClaimDOC Allowed:$1,507.75 Plan Savings: $60,414.64 Reduction: 98%
2. Philadelphia, PA
Hospital outpatient services for the treatment of lung cancer and radiation therapy treatments
High-Dollar Services:
Radiation Treatments (11): $252,951
Savings Summary:
Billed Charges: $252,951.00
ClaimDOC Allowed: $21,161.21 Plan Savings: $231,789.79 Reduction: 92%
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.
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