October 2022 | Get the latest from the best RBP advocates and auditors
Industry Perspective
Michelle Henaman
Senior Relationship Manager
The Art of Persuasion - RBP is Bad for Members
Human Resources Teams are tasked with developing benefit solutions that meet many needs. They recruit new employees with competitive offerings and retain employees by meeting healthcare accessibility needs, all while ensuring the number two corporate expenditures keep the board and CFO happy. To bring it all together, Brokers are trusted to give unbiased guidance and access to solutions. No problem, right? However, once you throw RBP into the conversation, more than likely, someone will utter the generic statement, “it’s bad for members.”
I have been with ClaimDOC for two years after spending 30 years working for the Blues and Aetna. My PPO client service experience gives me an incredible perspective on misperceptions that exist about RBP. It is professionally irresponsible to spread the narrative that RBP is bad for members. If you are tasked with advocating for members, why promote a deal-killer narrative without sufficient expertise to make that statement? Read more...
Audit Spotlight
Cynthia Swanson, RN, CPC, CEMC, CHC, CPMA
Senior Audit Manager
Audit Reveals Varied Costs for Spinal Surgery
In this Audit Spotlight, we focus on hospital inpatient charges for two members having spinal surgery and the related charges reported and billed by different hospitals. Each hospital reported/billed services using DRG code 454, defined as: Combined anterior/posterior spinal fusion with complications/comorbidities.
Costs for spinal surgery differ depending on the specific surgery, city, where surgery is performed - hospital inpatient, hospital outpatient, ASC, whether the patient has insurance or not, and other considerations. In addition to facility charges, there will be professional charges for the services of the surgeon(s), assistant surgeon(s), and anesthesia, as applicable. Other costs may include outpatient physical therapy, durable medical equipment, and pharmacy.
As healthcare costs continue to climb an upward slope, there is an escalated need for a closer assessment of healthcare claims to assist in identifying improper medical coding, medical billing errors, egregious charges, and 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. Houston, TX
Hospital outpatient services for the treatment spinal instabilities and related surgery
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
"Mandy is the best! I was just telling another employee how impressed I am by ClaimDOC's service and support. She made my day and alleviated stress that comes from going to the doctor."
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