August 2022 | Get the latest from the best RBP advocates and auditors
Industry Perspective
Ben Krambeck
CEO
Andrew Soha
VP of Business Development
Stop Paying More for Less
There is an abundance of non-fiduciary reference based pricing (RBP) vendors who charge a fixed cost per employee per month (PEPM), aka “repricers.” Repricers have convinced the employee benefits industry they provide employers the same capabilities and resources as co-fiduciary RBP vendors, such as ClaimDOC, for a fraction of the cost.
A simple cost comparison of ClaimDOC’s services tell a convincingly different story. After interviewing dozens of stop loss carriers, TPA partners, and insurance advisors there was no evidence to support the claim PEPM reference based pricing programs are less expensive. We also found they don’t work as promised and are unable to compete with ClaimDOC’s co-fiduciary RBP solution.
Trusting Your Reputation with Discount Service
The top repricers outright lie about the internal support and resources included in the PEPM fee. They downplay the absence of co-fiduciary indemnification which is a critical component necessary for a successful network replacement. Often a PEPM misleads buyers about the value of third-party á la carte services such as legal guidance and concierge member support, to fill the holes in their private equity owned RBP health plan time bomb. Read More...
Audit Spotlight
Cynthia Swanson, RN, CPC, CEMC, CHC, CPMA
Senior Audit Manager
Significant Variations in Charges for Routine Colonoscopy Services
In this Claims Audit Spotlight, we focus on colonoscopy services and their related charges. Colonoscopy is the most commonly performed gastrointestinal procedure, with over 16 million colonoscopies in the United States each year. Colonoscopies are performed as a screening for cancer, surveillance, and diagnostic to evaluate symptoms.
Typical costs for colonoscopy services vary widely due to a variety of factors. Charges depend on several factors:
Where the colonoscopy is performed, for example, in an ambulatory surgical center (ASC), hospital outpatient department, a physician’s office location or less seldom, in a hospital inpatient setting.
The applicable CPT/HCPCS code(s), modifier(s), diagnosis code(s), and other information reported/billed on the claim.
The type of insurance the patient has or no insurance/self-pay.
Health insurance plan language and specific details related to “screening” and “diagnostic” tests/procedures.
Typically, there is a charge for the facility component and a charge for the professional component (practitioner performing the procedure). 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. Pueblo, CO
Outpatient dialysis services for the treatment of end stage renal disease
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 Kyle has made the process of finding and nominating physicians a simple process. He is always prompt, professional, and helpful in answering questions. It is so nice to be able to interact with a person instead of a computer or auto-generated system."
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