Welcome to ClaimDOC.
ClaimDOC, LLC. (ClaimDOC) provides claim review and auditing services (Audit Program) to self-funded health plans (Plans) for Out of Network Claims or for Plans who have decided not to use a network for access to providers or facilities.
ClaimDOC’s Audit Program is set up to recognize the Medical Provider’s actual cost to deliver the service and to allow a fair margin above that cost.
Claim DOC utilizes recognized industry sources, with focus on geographic based Usual & Customary Reimbursement (UCR) along with Medicare & the Facilities’ annual cost reports submitted to the Centers for Medicare & Medicaid Services (CMS).
The ClaimDOC Guarantee
If ClaimDOC’s fee eliminates a financial benefit for the plan on ANY claim, then ALL usual & customary ClaimDOC services on that claim will be FREE to the plan.
ClaimDOC is an independent claim auditing and patient advocacy company
- Claim auditing for medical necessity and billing accuracy
- ERISA Appeal Management
- Member advocacy vs. Balance Bills
- Legal Defense in Litigation Scenarios
ClaimDOC's audit program
recognizes medical provider’s actual cost to deliver the service and ensures a fair margin above provider’s published cost.
Ensure profits for medical providers & facilities
Payment methodology is in line with the facility’s average reimbursements
Advocate for members and Benefit Plans against appeals or balance bills
Provide Sustainable payment options for health plans, providers, and facilities
Our Payment Process:
Efficient Turnaround On Payments To Providers.
Our Appeal/Balance Bill Process:
ClaimDOC as Co-Fiduciary to Commercial Employer Sponsored Self Funded Plan
The Importance of Auditing for Billing Errors
• Member treated at a hospital facility in central California
• Member was treated for chronic cholecystitis (chronic gallbladder issues common with recurring gall stones)
• Member received surgery which was charged at $15,825.44 (billed charges)
• Hospital facility then unbundled the same charges and billed them separately aka Unbundled Charges
• Total billed charges: $56,849.64
• Total Amount Plan Saved: $50,944.34
These are charges that never should have been included in the bill. ClaimDOC then reduced
the bill even further per its audit process in accordance with the Plan language, saving the Plan a total of
Fair Payment Solutions for Health Plans