October 2023 | Get the latest from the best RBP advocates and auditors
Industry Perspective
Amy Pellegrin
Senior Vice President and Chief Legal Officer
The Cost of Compliance
The many requirements of the Consolidated Appropriations Act of 2021 (CAA) have forced plan sponsors and the brokers guiding them to find compliance solutions. With tight deadlines and the threat of large penalties, this burden fell to independent third-party administrators who were forced to find off-the-shelf solutions from opportunistic tech companies. These vendors wisely solved a need created by new regulations by offering tools designed to help plans comply. While necessary to stay compliant, checking the box on these requirements has come at a cost for clients offering progressive plans not utilizing a traditional network. The cost is twofold. First, TPAs are passing along the cost of the tools to plan sponsors directly as a line item cost as part of their services agreement. Secondly, these solutions are not built for nor aligned with network-free solutions, creating a level of unintended friction. At ClaimDOC, we made the choice to invest in the necessary technology to offer our clients compliance solutions that create a better member experience without additional cost.
The savvy entrepreneurs who have entered this data/tech space in today’s environment must create a solution that appeals to a wide variety of plans while representing compliance to the clients. The problem with this reasonable approach is that these tools cannot address the nuances of our DirectAccess™ Plan and, as a result, could run the risk of actually confusing and disrupting the member experience. Providing pure pricing information ignores the most important thing all network replacement programs should be focused on: access. Cash price solutions that may be alternatives aimed at driving consumerism rely purely on transparency data that research has shown is incomplete and flawed. Read more...
Audit Spotlight
Cynthia Swanson, RN, CPC, CEMC, CHC, CPMA
Senior Audit Manager
Egregious Charges for Blood Collection/Venipuncture Services
In this Claims Audit Spotlight, we focus on claim examples where the provider reported and billed blood collection/venipuncture services.
We asked three (3) questions:
Is the provider really charging this much for a blood collection/venipuncture service (CPT code 36415)?
Is this a billing error?
Is the provider’s charge egregious for the type of service provided and billed?
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. Fort Worth, TX
Outpatient clinic dialysis treatments 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
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