The DOC

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

Industry Perspective

Bruce Hansen

Executive Vice President

Navigating Market Preference – Substance over Style

Five years ago, I joined a call with an experienced broker with a strong firm out of Kansas City. She had a client struggling with plan cost; yet, when we explained our solution, she didn’t believe it would work. She had heard of reference based pricing, but thought it was just conceptual and didn’t think plan sponsors actually did it. Fast forward five years and it feels like we are in a place where the broker community almost universally accepts that referenced base pricing works.

There is continued debate on the definition of ‘working’ and varying opinions from brokers on whether it suits their book of business. Regardless, for a broker to say it doesn’t work these days mostly makes them look ignorant. Instead, the question brokers ask is typically focused on what the market expects once they eliminate the network. Our perspective has always been that employers and their plan participants expect a very similar overall experience with moderate ease-of-use pain for significant financial gain. Viewing ourselves as Network Replacement instead of simply RBP allowed us to build properly from the ground up. Read more...

Audit Spotlight

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

Senior Audit Manager

Medical Coding and Billing Errors – Innocent Mistake or Intentional Misrepresentation?

The complexities surrounding medical coding, billing, and submitting an “accurate” claim are a given. Those in the business of healthcare will affirm that keeping up with annual CPT, HCPCS, ICD-10 code revisions/updates, variations of health plans guidelines/policy instructions, numerous Medicare laws, regulations, and other related healthcare matters give rise to both – ongoing challenges and opportunities to the revenue cycle process. It also shines a spotlight on ensuring healthcare providers/suppliers are compliant with the submission of medical claims, have the necessary supporting documentation for services reported/billed, and receive appropriate reimbursement for billed services.

There must be ongoing coordination, communications, and education to help ensure claims are routinely submitted accurately the first time. Refiling and rebilling claims due to medical and coding errors is inefficient and increases administrative expenses for all parties involved. 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. Statesboro, GA

Ambulatory surgical center services for the treatment of uterine endometriosis, adhesions, and infertility.

High-Dollar Services:

• Surgery: $70,169.75

Savings Summary:

Billed Charges: $70,169.75
ClaimDOC Allowed: $5,091.01
Plan Savings: $65,078.74
Reduction: 93%

2. Plant City, FL

Hospital outpatient treatment for knee sprain and related surgery

High-Dollar Services:

Operating Room: $81,491.08

Medical/Surgical Supplies: $10,503.76

Savings Summary:

Billed Charges: $127,757.56
ClaimDOC Allowed: $13,099.16
Plan Savings: $114,658.40
Reduction: 90%

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

Dallas is the best! He has helped me time and time again. He always gets back to me promptly and calls the doctor's office for me! I have never experienced customer service like that before. I asked him to look up doctors in my area, hoping he would put me on the right path. He sent me all the information I needed with the link, and I found a really great doctor. He is a sincerely wonderful member advocate.
 

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