U.S. employers are at a breaking point as healthcare costs continue to soar, and inflation tightens its grip across every sector. Blistering inflation, especially food and energy, combined with tight labor markets have driven average wage increases to almost double what employers were budgeting over the prior decade. The squeeze from increased payroll is putting plan sponsors in a vulnerable position.
Now comes the renewal. Dialing in renewal increases has historically been a game of cat and mouse with network business. Get a big renewal, negotiate, and worst-case scenario, get a quote from ClaimDOC to really put that finishing touch of pressure to keep the renewal at an 8-10% increase. “A Fair Renewal” that makes every CFO dislike their broker more than the broker ever knows. When a broker does the obligatory “how’s business” then shoves a big renewal in their face, there is someone in the room who wants nothing more than an excuse to fire them.
Word on the street is stop loss markets are getting bludgeoned this year on their network business. This has sent shock waves through the risk-taker community, and the losses aren’t just in the big carrier markets. Independent Third-Party Administrators (TPA) have provided a great mechanism for unbundling self-insured businesses. Nonetheless, these arrangements still primarily rely on networks that have been abysmal at protecting spend on facility claims.
To add more salt to the wound, there are risk-takers who migrated to the latest and greatest in underwriting technology. Read more...
Audit Spotlight
Cynthia Swanson, RN, CPC, CEMC, CHC, CPMA
Senior Audit Manager
Egregious Physician Charges for Screening Colonoscopy Services
In this Claims Audit Spotlight, we focus on a claim example where the physician reported and billed a routine screening colonoscopy procedure with place of service code 11, defined as office.
We asked three (3) questions:
Is the physician really charging this much for a routine screening colonoscopy service?
Is this an error on the physician claim?
Is the physician charge egregious for the type of service provided and billed?
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. Charleston, SC
Hospital outpatient services for the treatment of unstable angina and related procedure
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
"Lai is so helpful, she thinks of everything and is great with follow up. She is a great person to have in your corner when dealing with physicians. I'm so thankful for my Member Advocate!"
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