Why ClaimDOC?

ClaimDOC is a reference based pricing (RBP) company driven to deliver a successful program for you and your employees. Our clients typically save 25 to 35 percent within the first year of switching to ClaimDOC from a traditional carrier/network program. Creating savings is the easy part and we set the bar higher. Taking exceptional care of your members, building relationships with their providers and never backing away from a challenge is what sets ClaimDOC apart. Clients ready for RBP need to decide if they want to offer members discount service delivery or provide them unparalleled care with ClaimDOC.

Our Services

Comprehensive RBP with no hidden costs. We believe the following are necessary and should never be optional.

ClaimDOC As Co-Fiduciary

Volunteering to take on an elevated level of liability to act prudently and make decisions on behalf of the plan.

Comprehensive Medical Claim Auditing

We perform a line-by-line audit for medical necessity and billing accuracy. This is very different than generic repricing typically offered under RBP. Providers may not like it; however, they respect our process and the report we provide.

Billing Error Case Study

A 49-year-old female with acute appendicitis underwent outpatient surgery at a Houston, Texas, medical facility.
Billed charges: $81,467.30
ClaimDOC reduced: $74,665.16
Allowed: $6,802.14
ClaimDOC Savings: 92%

A breakdown of the reduced charges were as follows:
$21,099.00 – Egregious charge for CT Scan of Abdomen/Pelvis with Contrast (Hospital’s cost + 20% profit: $238.78 and Medicare allowed amount: $215.96)
$19,980.50 – Unbundled Medical Surgical Supplies (Rev Code 272)
$14,716.50 – Unbundled Surgery Charges (Rev Code 360)

Client Onboarding Team

Dedicated to promoting proper education and supporting your human resources team with regular meetings to ensure expectations of service delivery to members are being met.

ERISA Appeal Management

Review and respond to all provider appeals to the plan related to claim payment results.

Litigation Defense

Provide full legal management of disputes related to audit results and payment process. This includes direct internal consultation along with oversight of and payments for external legal services.

Pave The Way™

Our Pave the Way™ program works to educate both members and their providers to create an optimal outcome.

Balance Bill Support Program

The balance bill support program provides education on financial responsibility and relieves members of obligations to engage in disputes about payments to providers.

Member Advocacy

Our Member Advocates come to work every day to make a difference in the lives of our members. We work together in a collaborative environment that results in seamless service and enhanced member experience. Your people simply reach out to us whenever they have a question or concern, and we’ll take it from there.

“I just wanted to let you know what a fantastic customer service experience I had working with Emily to reconcile a statement. She was not only extremely helpful, but also efficient, and kind. I can’t remember ever having such a good experience with any other customer service representative (for any business) ever in my lifetime!”

“Hello, I just wanted to share with you the outstanding customer service I encounter today. This is a new insurance plan and I was running into some difficulty with a provider stating she was “out-of-network”. Fatima was knowledgeable, quickly calmed me down, and put my fears to rest. She followed up with me twice after our initial call to make sure I was satisfied and that I knew every step that she was taking to ensure the matter was getting handled. I work in customer service and it is nice to know that there are others who share the same values. Fatima should be commended for outstanding customer service.”

“The whole group has been wonderful for all of our employees. I can’t tell you enough how everybody has been very pleased with your people getting all of our physicians on board. I made sure to tell HR how happy everybody was.”


Meet Our Member Advocates


What Is Reference Based Pricing?

Reference-based pricing (RBP) is a generic term used to describe a type of medical claim pricing utilized by self-insured medical plans. Traditional programs rely on a carrier or network with provider contracts. Those contracts define a discount based off billed charges (the chargemaster). The billed charge becomes the reference point for calculation and the reference point changes from hospital to hospital without consistency or regulation. The lack of reference point consistency, along with outlier provisions, makes it impossible to understand the value of the discount or know the cost of services. RBP simply looks to define a more consistent reference point, with Medicare rates being most commonly used, due to its quantifiable and widely acceptable industry-recognized standards. Plans then apply a premium above Medicare and make payment to the provider based on that markup. More sophisticated vendors, like ClaimDOC, utilize audits and multi-factored data to determine facility-specific payments.

The principle of using a consistent reference point is what defines RBP and what drives savings to the plan sponsor. RBP does not define the level of quality and services each vendor provides, making services evaluation the most critical aspect to vendor selection.


Want More Information?

Please contact us with any questions.

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Success Stories