The DOC

March 2023 | Get the latest from the best RBP advocates and auditors 

Industry Perspective

Brad Hansen

VP of Provider Relations

Price Transparency Buzzkill?

The last couple Industry Perspectives have been somewhat introspective, so I thought I’d share some views on an external topic which is top-of-mind for a lot of our distribution partners. As has been mentioned previously, ClaimDOC’s volume of work allows us to look at things from both a wide-angle and telephoto lens based on our experience and execution.

This month, I want to focus on price transparency. As most of you know by now, hospital price transparency is the government mandate for hospitals to be transparent with their prices for healthcare services including those negotiated with health plans. Now, of course, health plans have a similar disclosure requirement, so there is even more publicly available data to theoretically help consumers and health plans drive down the cost of care.

These well-intended laws are based on the idea that more transparency will benefit patients because “sunshine is a good disinfectant,” and more consumer awareness and competition will help the end user. The dream of course is for these data to be useful for health plans and consumers. While I agree with the premise, in reality, it’s much more complex than that for a variety of reasons. Read more...

Audit Spotlight

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

Senior Audit Manager

Air Ambulance Mileage on Claim Raises Auditor’s Red Flag

In this Audit Spotlight, we focus on an air ambulance claim where the ClaimDOC auditor questioned the milage being reported/billed on the claim.

An air ambulance company in Florida billed air ambulance services on the UB-04 claim/electronic equivalent, 837I. The primary medical diagnosis codes on the claim were reported as rib fractures and traumatic hemothorax due to bicycle accident.

Upon review of the ambulance trip record received, it was verified that according to the medical record documentation, the air ambulance mileage provided was 35 miles, not 350 miles as reported and billed on the claim. 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 of neck and back pain following a motor vehicle accident

High-Dollar Services:

• CT Scans: $94,688.63
  
  

Savings Summary:

Billed Charges: $110,480.76
ClaimDOC Allowed: $1,044.17
Plan Savings: $109,436.59
Reduction: 99%

2. Bridgeport, CT

Physician services for reconstructive breast surgery due to breast cancer

High-Dollar Services:

Surgery: $148,800

Savings Summary:

Billed Charges: $148,800
ClaimDOC Allowed: $2,949.74
Plan Savings: $145,850.26
Reduction: 98%

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

"Braden is amazing! He has been outstanding in his follow-up and a relief to me while navigating provider coverage for my son. His customer service makes me feel like I’m a top priority daily. He anticipates needs before I even think to ask."
 

Visit our Website!

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

You received this email because you signed up on our website or made a purchase.