Audit of newborn delivery results in major client savings

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.