The DOC

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

Industry Perspectives

Stephanie Mohr

Senior Relationship Manager

4 Must-Do's for Nailing RBP Open Enrollment

Open enrollment season is a bustling time of year, especially for groups going live on Jan. 1. Not only are people prepping for holiday feasts, but they’re also reviewing new benefits and making sure all elections are finalized before the deadline. Each year, human resources teams are tasked with making this process as easy and, dare I say, enjoyable as possible.

For groups taking the leap to a new approach like reference-based pricing — a health plan that’s far from traditional — brokers and HR may see this as a daunting task. Around this time, the fear of the unknown can build, and some HR leaders might find themselves asking, “How are we going to accomplish this?” Read more.

Audit Spotlight

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

Senior Audit Manager

2026 Brings New Codes, Guidelines and Medical Billing Considerations

The complexities surrounding medical coding, billing and submitting an accurate claim is a given. Entities in the business of healthcare will attest: keeping up with ongoing CPT, HCPCS, ICD-10 code revisions/updates; variations of health plans' guidelines and policy instructions; numerous Medicare laws; regulations; and other related healthcare matters give rise to both ongoing challenges and opportunities to the revenue cycle management process. It also shines a spotlight on three key areas:

• Ensuring healthcare providers/suppliers are compliant with the submission of medical claims.
• Necessity of having supporting documentation for all reported/billed services and procedures.
• Receipt of accurate and proper reimbursement.

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. Our 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.

York, Maine

One-day hospital stay for the treatment of pain due to internal orthotic device and related surgery

Traditional Network Plan

• Hospital Bill: $78,866.50
• Median Commercially Contracted Price
  • $43,587.11

• Patient Responsibility 20% Coinsurance:
  •  $8,717.42

DirectAccess+

• Hospital Bill: $78,866.50
• ClaimDOC Allowable
  • $25,174.53

• Patient Responsibility 20% Coinsurance:
  • $5,034.91

• Plan Savings: $18,412.58
• Member Savings: $3,682.51

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

"Shannon was sincerely a blessing. We just switched insurance, and one of my providers was telling me they wouldn’t take my insurance. Shannon contacted them, kept me in the loop the entire time and worked everything out with my provider. She really went the extra mile. I appreciate everything she did. Thank you!"

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