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JUL 2020Get the latest from the best RBP advocates and auditors 

Audit Spotlight
Cynthia Swanson
Cynthia Swanson
RN, CPC, CEMC, CHC, CPMA, Senior Audit Manager


ClaimDOC' s comprehensive line-by-line auditing uncovers errors that basic repricing and auto-adjudication do not catch, leading to greater savings to health plans and beneficiaries. Our audit team analyzes all types of healthcare claims for a variety of potential concerns including excessive usual and customary charges, duplication of claims, correct coding edits, unbundling of services, and others. Our claims review is not intended to impact care decisions or medical practice.

Case Scenario

Member was admitted to the hospital as an inpatient for elective spinal surgery, resulting in a seven-day stay. The hospital claim and charges submitted to insurance totaled $631,087.06. The primary diagnosis reported on the claim reflects lumbar spinal stenosis.

In this case, high dollar charges included seven days of room and board for $55,650.00, medical-surgical supplies for $401,294.86, operating room for $121,986.23, and anesthesia for $17,818.23. Our review of the hospital itemized bill identified unbundled services considered to be part/partial to other reported services billed. Examples included charges for nursing services, medical/surgical supplies, respiratory services, and equipment monitoring services. Due to the high charges billed for the spinal implants at $346,734.04, we requested a hospital invoice for these implant services so we could analyze the specific hardware costs. The hospital did not however furnish this specific information to us.

After the unbundled items were removed from the cost-to-charge total and pricing comparison were performed, the Medicare DRG rate resulted in a higher price.

Below is an overview of the hospital charges billed and related ClaimDOC pricing and savings:

Total billed charges: $631,087.06

ClaimDOC Allowed: $108,341.70

Plan Savings: $522,745.36

Percentage of Savings: 83%

The Takeaway

Over-inflated charges and unbundling of hospital services considered part and partial to other reported/billed services were observed on the itemized bill. While hospitals may charge any amount they choose for provided services, egregious fees and billing unbundled services can complicate matters for members to understand their bills and payments, impact the collection of patient balances, build a reputation of hospitals charging high fees, create burdens for patients having no insurance and a host of others.

Our goal at ClaimDOC is to use benchmark charges and costs nationally to negotiate fair and ethical payments. Employers turn to us to seek to establish fair reimbursement rates for their plans allowing them to save money and provide richer benefits to their employees. A win-win for everyone.

Client Savings

Comprehensive line-by-line claim auditing by healthcare professionals is used to uncover errors typically not caught. See the savings below and know that together we can make healthcare affordable.

1. Sacramento, CA

Two-day hospital stay for right hip replacement surgery

High-Dollar Services:
  • Operating Room: $52,532.00
  • Implant(s): $32,750.00
  • Anesthesia: $8,430.00

Savings Summary:

Billed Charges: $117,566.82
ClaimDOC Allowed: $19,134.69
Plan Savings: $98,432.13
Reduction: 84%

2. Salem, VA

Hospital outpatient services for surgical repair of broken leg

High-Dollar Services:
  • Implant(s): $40,123.00
  • Operating Room: $27,453.53
  • Medical/Surgical Supplies: $21,224.00
Savings Summary:

Billed Charges: $106,417.13
ClaimDOC Allowed: $16,383.15
Plan Savings: $90,033.98
Reduction: 85%

3. Dothan, AL

Hospital outpatient services for gallbladder surgery

High-Dollar Services:
  • Medical/Surgical Supplies: $60,462.49
  • Implant(s): $18,664.22
Savings Summary:

Billed Charges: $99,514.33
ClaimDOC Allowed: $7,948.89
Plan Savings: $91,565.44
Reduction: 92%

4. Worcester, MA

One-day hospital stay for treatment of leukemia

High-Dollar Services:
  • Pharmacy: $20,322.89
  • Laboratory: $19,751.00
  • CT Scans: $5,868.00
Savings Summary:

Billed Charges: $58,638.49
ClaimDOC Allowed: $13,754.30
Plan Savings: $44,884.19
Reduction: 77%

5. Indianapolis, IN

Hospital outpatient services for treatment of leg fracture and dislocation of ankle

High-Dollar Services:
  • Operating Room: $27,293.10
  • Implant(s): $8,372.00
  • Emergency Department: $5,497.00
Savings Summary:

Billed Charges: $56,587.35
ClaimDOC Allowed: $9,896.81
Plan Savings: $46,690.54
Reduction: 83%

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.

Broker Experience

Account Manager feedback from a Broker

“I want you to know how impressed I am with your demeanor, professionalism, capability and responsiveness. I’ve been in this industry a long time and work with a lot of vendors and rarely do I come across someone with your combination of skills. I genuinely mean that and you have a standing job offer with our firm and any of our partner firms. We so appreciate all your help.”

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