The DOC

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

Industry Perspective

Amy Pellegrin

Senior Vice President and Chief Legal Officer

Multiplan Probe — Who Hired Them Anyway?

The knives are out following an article in The New York Times that analyzes the business of out-of-network pricing by Multiplan and its fee structure. Within hours of the story, the American Hospital Association submitted a request for a federal probe to the Department of Labor, apparently aghast by the notion that a company would create a business model that profits from its own pricing structure and saddles patients with bills — bills that the hospitals send, of course. While Multiplan is the current target of the attack, employers are on edge determining if they will be liable by joining the millions who willingly paid Multiplan’s fees to price out-of-network claims. With this latest Multiplan probe and a wave a of employee-led lawsuits alleging fiduciary failures by large employers, could accountability finally be on the way for this industry where bad actors have continuously been profiting at the expense of American workers? Read more...

Audit Spotlight

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

Senior Audit Manager

Poisonous Snake Venom Bite As Painful as Hospital Bill for Treatment

ClaimDOC's comprehensive line-by-line review of claims uncovers errors that basic claim repricing and auto-adjudication does not catch, leading to greater savings for health plans and its plan members. Our audit team analyzes all types of healthcare claims for a variety of potential concerns including excessive usual and customary charges, duplication of claims, incorrect coding, unbundling of services and many others. Our claims review is not intended to impact care decisions or medical practice.

In this Claims Audit Spotlight, we focus on high dollar hospital charges for emergency outpatient services and antivenin treatment reported/billed on the UB-04 claim/electronic equivalent.

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

Hospital outpatient services for the treatment of chest pain

High-Dollar Services:

• CT Scan: $13,873.00

Savings Summary:

Billed Charges: $56,306.00
ClaimDOC Allowed:$1,688.13
Plan Savings: $54,617.87
Reduction: 97%

2. Las Vegas, NV

Four-day hospital stay for the treatment of cellulitis of left arm and related procedure

High-Dollar Services:

• Pharmacy: $30,181.00

Savings Summary:

Billed Charges: $117,954.00

ClaimDOC Allowed: $9,727.66
Plan Savings: $108,226.34
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.

Member Experience

Feedback from a Member

"My Member Advocate, Marissa, has been a true gem to work with. My company just started with ClaimDOC, and I needed medical care at the beginning of this year. She has been thorough and has always followed up with my responses in a timely manner. I commend you on having such a wonderful employee."

Visit our Website!

Whether you're an Employer, Provider, Broker, Stop Loss Carrier, or Member, get valuable information 24/7 by visiting www.claim-doc.com.

You received this email because you signed up on our website or made a purchase.