Audit of outpatient procedure results in a 99% plan savings

ClaimDOC’ s comprehensive line-by-line auditing of claims uncovers errors that basic claim 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

The member received a trigger point injection procedure which was performed in an outpatient ambulatory surgical center (ASC) for the relief of muscle and low back pain. The physician performing the service submitted their CMS-1500 claim to insurance which totaled $12,806.00. The primary ICD-10-CM diagnosis reported on the claim was M79.18 – Myalgia, other site (muscle pain).

In this case, two procedure codes were reported/billed on the claim, CPT code 20553, defined as, trigger point injection (TPI), and CPT code 76942 defined as, ultrasound guidance for needle placement or biopsy. High dollar charges included $10,794.00 for the TPI and $2,012.00 for the ultrasound needle guidance.  

Based on the service codes reported, this procedure involves the physician injecting a therapeutic agent (i.e., medication) into multiple trigger points, 3 or more (discrete spots within bands of muscle) under image guidance.

Our review of usual, customary, and reasonable (UCR) charges for physicians performing these identical services in the state of Arizona where services were performed, identified the following:

  • CPT code 20553 physician charge at the 60th percentile = $200 and at the 90th percentile = $250
  • CPT code 76942-26 (professional component) at the 60th percentile = $300 and at the 90th percentile = $672.90.
  • Combined UCR physician charges at the 60th percentile = $500 and at the 90th percentile = $922.90.

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

  • Total physician billed charges: $12,806.00
  • ClaimDOC Pricing: $95.08
    (Based on Medicare 2020 physician fee schedule and designated locality, for both CPT codes with markup)
  • Plan Savings: $12,710.92
  • Percentage of Savings: 99%

The Takeaway

Over-inflated physician charges were observed on the CMS-1500 claim form. While providers may charge any amount they choose for procedures/services performed, egregious physician fees can complicate matters for members to understand their bills and payments, impact the collection of patient balances, build a reputation of physicians and group practices 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 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.