The DOC

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

Industry Perspective

Ben Krambeck

Chief Executive Officer

Contract Heavy RBP – Will the Real Slim Shady Please Stand Up

Which hospitals do you have a contract with?

That’s the question we frequently hear when we talk with brokers and representatives of self-funded health plans who have lived in the world of network-based health plans while costs continue to skyrocket out of control. These decision-makers come to us looking for a new solution, but they view contracts and access to care as the same thing, and they ignore (or are simply unaware of) some of the shortfalls of this strategy.

First, there is a real timing challenge to negotiating and implementing these agreements, which can hold up a member’s access to care. With the consolidation in the health care provider landscape, local decision-making has been replaced with system-based negotiations involving multiple departments often far removed from the locality where the physicians and hospital care for patients. As a result, it is not uncommon for discussions and negotiations to take many months – even years – to get to an agreement. Members and their families can grow old waiting for these deals to get done. Read more...

Audit Spotlight

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

Senior Audit Manager

Egregious Charges for Behavioral Health Service Raises a Red Flag

In this Claims Audit Spotlight, we focus on a claim example where a licensed clinical social worker (LCSW) billed a questionable fee/charge for a service that made our red flag go up.  

We pondered three (3) questions:

1. Is the practitioner really charging this much for the service?
2. Is this an error in practitioner billing?
3. Is the charge egregious for the type of service provided and 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. Fort Wayne, IN

Ground and air transport to between hospitals for the treatment of stroke

High-Dollar Services:

• Air Ambulance: $220,450

  
  
  

Savings Summary:

Billed Charges: $232,050
ClaimDOC Allowed: $11,959.62
Plan Savings: $220,090.38
Reduction: 95%

2. Davenport, FL

Three-day hospital stay for the treatment of right kidney cancer and related surgery

High-Dollar Services:

Operating Room: $197,244.20

Savings Summary:

Billed Charges:$274,565.14

ClaimDOC Allowed: $16,871.20
Plan Savings: $257,693.94
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

"Levi has been OUTSTANDING. He proactively communicates so I don't have to worry about issues. He has phenomenally clear messaging, chases things down, and has made my plan feel so smooth!" 

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