The DOC

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

Industry Perspective

Michelle Henaman

Senior Relationship Manager

Wellness: Seeing the Forest Through the Trees

Employee Wellness. Over the course of several years, it’s been considered everything from a buzzword to a magic bullet in the area of Human Capital. No doubt, it’s a necessary element for a positive workplace culture. It is also, for some, a proven employee retention and recruitment tool. The companies available to provide such programs are plentiful and more than willing to sell their version of the perfect wellness program at a significant cost.

But, sometimes, it’s hard to see the forest through the trees. Have you considered that it may be highly unnecessary to install a separate “wellness” program? What if you were able to leverage a basic and foundational element of your employee benefits package – your health plan – with holistic wellbeing outcomes? Have you considered that if designed with intention, your health plan itself can harvest the elements necessary to provide your employees with holistic wellness? What if your health plan itself isn’t providing the opportunities to give your employees the holistic wellness they deserve? Instead, the worry of high deductibles, limited benefits, and year-over-year cost shifting to the employee is what is causing the need to have a wellness program. What if you could redeploy your health plan with the intent to increase your employees’ wellbeing?

A recent MetLife Employee Benefits Trend Study suggests corporate wellness doesn’t have to be a program bought from a third party – with soft ROI’s and added administrative expense. It starts with building a corporate culture where people feel appreciated and taken care of by providing a health plan that allows employees to effectively take care of their family’s health. Employees need a plan that assists with navigating the always changing, extremely complicated world of healthcare, while also removing high premiums, and increasing deductibles and out-of-pocket costs. A few takeaways from the survey: Read More...

Audit Spotlight

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

Senior Audit Manager

Ongoing Price Transparency Initiatives - Egregious Charges

In this Claims Audit Spotlight, we focus on a claim example where our audit team did a double take when reviewing the claim and related charges. We considered three (3) questions:

1. Is the hospital really charging this much for the diagnostic test?
2. Is this an error in hospital billing?
3. Is the hospital charge egregious for the service provided and billed?

A 45-year-old male was seen at a hospital outpatient department in Saint Petersburg, Florida, for a CT scan of the abdomen and pelvis with contrast. The diagnosis on the claim listed acute appendicitis. 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. Portland, ME

Outpatient clinic dialysis treatments (4) for the treatment of end stage renal disease

High-Dollar Services:

• Pharmacy: $38,249.98
  
  
• Dialysis Treatment (4): $33,645.72

Savings Summary:

Billed Charges: $72,179.70
ClaimDOC Allowed: $1,645.68
Plan Savings: $70,534.02
Reduction: 98%

2. Valparaiso, IN

Hospital outpatient services for the treatment of left foot wound and staph infection

High-Dollar Services:

Pharmacy: $104,013

Savings Summary:

Billed Charges: $127,643
ClaimDOC Allowed: $15,022.98
Plan Savings: $122,620.02
Reduction: 88%

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

"High five to the best member advocate! I didn't realize how much better insurance can be with the help and support of a Member Advocate. Amanda's communication makes me feel like a valued person, not another name and phone number that gets lost in the process. Thank you!"
 

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