The DOC

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

Industry Perspective

Matt Schwartzkopf

Associate Counsel

Medical Debt & Credit Impairment — Fear Tactics Taking a Hit

In case you missed it, the Biden administration recently announced that the Consumer Financial Protection Bureau would work toward removing medical debt from credit reports of more than 15 million Americans and, ostensibly, ban medical debt from credit reports period. Back in 2023, the top three credit bureaus — Experian, TransUnion and Equifax — moved to remove all unpaid medical debt that had an initial balance below $500. Not surprisingly, medical debt relief has proven to be popular with most people. 

Notice I said most people. One person is not too keen on the idea. Read more...

Audit Spotlight

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

Senior Audit Manager

So Many Ways to Code and Bill Healthcare Services Improperly

In this Audit Spotlight, we focus on coding and billing errors ClaimDOC’s medical auditors identify on claims reported/billed by hospitals. 

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

Everyone agrees revenue cycle management (RCM) is a complex process to manage financial operations related to billing and revenue collection for provided healthcare services. The process begins with appointment scheduling, patient registration, charge capture, coding of services provided, data entry, billing claims and accounts receivable follow-up. Due to the multiple components, errors easily occur.

The goal of reducing medical coding/billing errors must be a component of a provider’s ongoing internal compliance plan. If medical providers are not routinely performing risk assessments of their internal coding and billing processes/procedures, it can cause a host of problems. Some providers perform in-house coding/billing functions while others elect to outsource their coding/billing to an outside billing company. 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. Zephyrhills, Florida

One-day hospital stay for the treatment of spinal stenosis with related surgery.

Traditional Network Plan

• Hospital Bill: $124,707.16
• Median Commercially Contracted Price
  • $37,295.00

• Patient Responsibility 20% Coinsurance:
  • $7,459.00

DirectAccess+

• Hospital Bill: $124,707.16
• ClaimDOC Allowable
  • $18,209.54

• Patient Responsibility 20% Coinsurance:
  • $3,641,91
• Plan Savings: $19,085.46
• Member Savings: $3,817.09

2. Toledo, Ohio

Hospital outpatient services for the treatment of genetic susceptibility to ovarian cancer with related surgery.

Traditional Network Plan

• Hospital Bill: $114,585.50
• Median Commercially Contracted Price
  • $30,760.62

• Patient Responsibility 20% Coinsurance:
  • $6,152.12

DirectAccess+™

• Hospital Bill: $114,585.50
• ClaimDOC Allowable:
  • $11,676.39

• Patient Responsibility 20% Coinsurance:
  • $2,335.28
• Plan Savings: $19,084.23
• Member Savings: $3,816.85

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

"My Member Advocate, Amanda, is always quick to respond to me when I have a question or a provider nomination. Her emails are friendly and uplifting. Thank you, Amanda!"

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