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

Background

ClaimDOC' s comprehensive line-by-line auditing uncovers errors that basic repricing and auto-adjudication does 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 for delivery of newborn by caesarean section, resulting in a three-day hospital stay. The hospital claim and charges submitted to insurance totaled $96,684.88. The primary diagnosis reported on the claim was maternal care for abnormal presentation of an infant.

In this case, high dollar charges included operating room for $41,996.41, three days of room and board for $17,711.88, recovery room for $16,804.71, and pharmacy for $13,633.30. Our review of the hospital itemized bill identified unbundled services considered to be part/partial to other reported services billed. Examples included charges for routine nursing care services, medical/surgical supplies, and laboratory services.

Additionally, we noted egregious billing for pharmacy/medication services. For example, the charge for one (1) Ibuprofen 600 mg tablet was $53.70. A typical hospital supply cost for one (1) Ibuprofen 600 mg tablet is 10 cents. Another drug, one (1) Oxycodone, 5 mg tablet was billed in the amount of $68.70. A typical hospital supply cost for this medication is $53.00 for a supply of 100 tablets. Lactated Ringer's intravenous (IV) solution 1,000ml was charged out at $1,212.00 and a typical hospital cost for this IV solution is $7.06.

The claim was priced based on the hospital’s cost-to-charge allowances minus the identified unbundled services resulting in higher reimbursement when compared to the Medicare Diagnosis Related Group (DRG) amount of $6,090.06.

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

Total billed charges: $96,684.88

ClaimDOC Allowed: $12,064.66

Plan Savings: $84,620.22

Percentage of Savings: 88%



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 seeking 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. Hermitage, TN

Six-day hospital stay for intestinal abscess

High-Dollar Services:
  • CT Body Scans: $34,809.81
  • Pharmacy: $21,798.45
  • Room & Board: $12,246.00

Savings Summary:

Billed Charges: $79,247.79
ClaimDOC Allowed: $9,353.09
Plan Savings: $69,894.70
Reduction: 88%



2. Mountain View, CA

Seven-day hospital stay due to elective back surgery

High-Dollar Services:
  • Medical/Surgical Supplies: $401,294.86
  • Operating Room: $121,986.23
  • Room & Board: $55,650.00
  • Anesthesia: $17,818.23
Savings Summary:

Billed Charges: $631,087.06
ClaimDOC Allowed: $108,341.70
Plan Savings: $522,745.36
Reduction: 83%



3. San Antonio, TX

Three-day hospital stay for bladder cancer surgery

High-Dollar Services:
  • Operating Room: $27,546.08
  • Medical/Surgical Supplies: $16,020.00
  • Anesthesia: $9,984.68
Savings Summary:

Billed Charges: $91,798.64
ClaimDOC Allowed: $22,122.56
Plan Savings: $69,676.08
Reduction: 76%



4. Santa Ana, CA

Nineteen-day hospital stay for brain hemorrhage

High-Dollar Services:
  • Pharmacy: $59,799.90
  • CT Head Scans: $30,497.85
  • Respiratory: $27,136.00
  • Emergency Room: $14,799.57
Savings Summary:

Billed Charges: $295,016.26
ClaimDOC Allowed: $71,842.40
Plan Savings: $223,173.86
Reduction: 76%



5. Chillicothe, OH

One-day hospital stay for pelvic surgery

High-Dollar Services:
  • Operating Room: $42,617.67
  • Anesthesia: $5,920.80
  • Room & Board: $3,360.00
Savings Summary:

Billed Charges: $55,863.93
ClaimDOC Allowed: $15,412.61
Plan Savings: $40,451.32
Reduction: 72%



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

Last week I was trying to contact multiple companies over the phone and online, none of them connected me with a real person right away. I was either placed in a queue with a long wait time or was told by an automated service to wait for a callback. I am so thankful to have a direct number to my ClaimDOC Member Advocate Katy. She makes my life so much easier. I’ve said it many times, but I am so appreciative to have direct access to an advocate to answer my questions and resolve issues. Thank you ClaimDOC!

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