The DOC

February 2025 | Get the latest from the best RBP advocates and auditors 

PBMs: Are You Getting Good Advice? – Part 2

In the second half of our discussion on PBMs, Marc A. Sweeney, Pharm.D., BCMAS, Trevor Daer and Mike Kroupa return to give their takes on the drug market and trends impacting the pharmaceutical industry.

In this episode, Danielle Young leads the trio of experts through a discussion on the intricacies of international drug sourcing, specialty drugs and GLP-1s. They also explain why the healthcare industry needs to see more cost-effective prescribing as opposed to searching for the best prices on the newest and most expensive drugs.

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Audit Spotlight

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

Senior Audit Manager

Egregious Physician Charges for Varicose Vein Procedures

There are multiple treatment options for varicose veins, including endovenous laser ablation, sclerotherapy, ligation with or without striping, and others. Some procedures are performed in a physician’s office location while others may be performed in an ambulatory surgery center or hospital outpatient surgery department.

There are also low-cost options to vascular surgery; recommendations for the most appropriate treatment options are determined by the practitioner. Many insurance plans cover varicose vein treatment that is deemed medically necessary. Treatments for cosmetic reasons are typically not covered. Read more...

DirectAccess+ Savings

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. The audit team performs line-by-line claim audits to help clients and members maximize their savings. Below is one recent audit result showcasing substantial savings.

Inverness, Florida

Eight-day hospital stay for the treatment of atherosclerotic heart disease and related surgery

Traditional Network Plan

• Hospital Bill: $540,452.51
• Median Commercially Contracted Price
  •  $109,060

• Patient Responsibility 20% Coinsurance:
  •  $21,812

DirectAccess+

• Hospital Bill: $540,452.51
• ClaimDOC Allowable
  • $56,813.39

• Patient Responsibility 20% Coinsurance:
  • $11,362.68

• Plan Savings: $52,246.61
• Member Savings: $10,449.32

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

"Corbin not only performed his job well, but did so with incredible speed, professionalism and care. I have felt as if a member of my family were helping me. This is critical when you have possible health issues. Corbin is not only a great employee, I believe every organization would benefit from having someone like him."

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