The DOC

December 2024 | Get the latest from the best RBP advocates and auditors 

When the 'Easy' Plan Isn't Member-Friendly

There's no easy button when it comes to creating a superior health plan solution. While BUCAs may seem like the simplest solution on the surface, they aren't all they claim to be.

Michelle Henaman and Heidi Martinez offer an inside look at a key component of reference-based pricing that helps solve member issues and ensures their medical plans run smoothly. In this episode of ClaimTalk: RBP From the Front Lines, they explain why settling for an inferior product, whether it's through a traditional network or RBP, creates more issues for both the company sponsoring the plan and its employees.

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Audit Spotlight

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

Senior Audit Manager

New Codes, Guidelines, Medical Billing Considerations in 2025

The complexities surrounding medical coding, billing and submitting an accurate claim the first time is a given. Anyone in the business of healthcare will attest that keeping up with CPT, HCPCS and ICD-10 code revisions and updates, variations of health plans guidelines and policy instructions, numerous Medicare laws, regulations, and other related healthcare matters give rise to ongoing challenges and opportunities to the revenue cycle process.

It also shines a spotlight on ensuring healthcare providers and suppliers are compliant with their coding, billing and submission of medical claims, have supporting documentation for reported and billed procedures, and receive 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. The 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.

Charleston, West Virginia

Fourteen-day hospital stay for the treatment of chronic left foot osteomyelitis and related surgery

Traditional Network Plan

• Hospital Bill: $121,088.42
• Median Commercially Contracted Price
  •  $88,964.09

• Patient Responsibility 20% Coinsurance:
  •  $17,792.82

DirectAccess+

• Hospital Bill: $121,088.42
• ClaimDOC Allowable
  • $37,008.61

• Patient Responsibility 20% Coinsurance:
  • $7,401.72

• Plan Savings: $51,955.48
• Member Savings: $10,391.10

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

"Brittany is exactly the type of person who should be working in the healthcare industry. She has the perfect balance of compassion and professionalism. She went above and beyond her responsibilities to ensure I was cared for. I am eternally thankful for her hard work on my behalf."

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