The DOC

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

Industry Perspective

Brad Hansen

VP of Provider Relations

Quality Metrics – Don’t Make Assumptions Based on Headlines

I recently came across a study dealing with “evidence-based medicine” in primary care (Ebell MH, Sokol R, Lee A, et al. How good is the evidence to support primary care practice? BMJ Evidence-Based Medicine 2017; 22:88-92). A quick scan of the article indicated the authors reviewed recommendations for treatment in a popular, primary care-oriented reference frequently consulted by physicians (i.e., Essential Evidence). Having worked in health care administration and health policy for most of the past 30 years, I am familiar with Essential Evidence and its widespread use, so naturally I wanted to learn more. Read more...

Audit Spotlight

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

Senior Audit Manager

Egregious Charges for Anesthesia Services Raises Red Flags

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 Audit Spotlight, we focus on egregious charges for anesthesia services reported/billed on the CMS-1500 claims/electronic equivalent.

As healthcare costs continue to climb an upward slope, an escalated need exits 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. New York, NY

Physician services for surgical removal brain malignancy

High-Dollar Services:

• Surgery: $51,776.00

Savings Summary:

Billed Charges: $51,776.00
ClaimDOC Allowed:$3,906,45
Plan Savings: $47,869.55
Reduction: 92%

2. Ocala, FL

Hospital outpatient services for the treatment of left radial fracture and related surgery

High-Dollar Services:

• Operating Room: $66,985.82

Savings Summary:

Billed Charges: $157,983.05

ClaimDOC Allowed: $16,666.89
Plan Savings: $141,316.16
Reduction: 89%

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, Kelsey, has been very attentive to me. I had a provider who had a lot of questions, and Kelsey was patient in answering all of them. I really like that she keeps me informed on the progress of my provider nominations and she gives me great information."

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

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