July 2023 | Get the latest from the best RBP advocates and auditors
Industry Perspective
Stephanie Mohr
Senior Relationship Manager
New Client Implementation – Broker Skills Prove Vital
We often find ourselves grappling with the fear of the unknown, preventing us from taking bold steps toward positive shifts in our organizations. Particularly in the health insurance space, embracing change can be scary, especially when it has the potential to impact employees and their families. At ClaimDOC, we frequently come across prospects who, deep down, know they need to take control of their healthcare spend and try something new, but hold back due to fear of the unknown. Even after they receive compelling proposals from supportive brokers, showcasing 30-40% savings on healthcare spend for the first year and the extensive member support ClaimDOC offers as a fiduciary partner, there is often hesitation to fully embrace the reference based pricing (RBP) network replacement model.
Shifting mindsets and letting go of something that has been deeply ingrained in us as an essential component of a health insurance plan can be uneasy, but not impossible. So why do so many organizations prefer to maintain a financially unhealthy relationship with their traditional network? Read more...
Audit Spotlight
Cynthia Swanson, RN, CPC, CEMC, CHC, CPMA
Senior Audit Manager
Everything is Bigger in Texas – Including Physician Charges
ClaimDOC’s comprehensive line-by-line auditing 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, correct coding edits, unbundling of services, and many others. Our claims review is not intended to impact care decisions or medical practice.
In this Audit Spotlight, we focus on a physician claim example where our audit team reviewed the claim for the procedures reported/billed and the related physician charges. We raised the red flag and asked three (3) questions:
Is there a mistake in physician billing on this claim?
Is the physician really charging this much for the billed procedures?
What are other physicians in the same or surrounding area charging for the same services? 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. Inverness, FL
Hospital outpatient services for the treatment of acidosis, vomiting blood and altered mental status
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
"Allyson is absolutely the best! She responds quickly and thoroughly and explains everything very clearly. She is a wonderful Member Advocate and has helped me numerous times over the last few months. ClaimDOC is so so lucky to have Allyson representing you, and I am so so lucky to have Allyson in my corner!"
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