Audit of hospital inpatient services results in an 89% 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 for health plans and their plan members. 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 many others. Our claims review is not intended to impact care decisions or medical practice. In this claims audit, we focus on hospital inpatient services provided to an individual who had surgery for the condition of spinal degeneration.

Case Scenario

The plan member was admitted to a hospital located in the state of Texas and had a one (1) day length of stay. The primary ICD-10-CM diagnosis reported on the insurance claim was M51.16, defined as, Intervertebral disc disorder with radiculopathy, lumbar region. The hospital submitted its services on a UB-04 claim form/electronic equivalent to insurance with total charges of $390,789.00.

In this case, high dollar charges included the operating room for $54,382.00, medical implants for $215,311.00, medical/surgical supplies for $87,630.76, anesthesia for $7,822.08, laboratory for $7,683.10 and pharmacy for $5,723.36. Other services included charges for recovery room, radiology, electrocardiogram, physical therapy, and occupational therapy.

Charges for services performed by the surgeon(s), assistant(s) at surgery, anesthesiologist(s), or CRNA(s), are commonly submitted by these practitioners as professional services, separate and distinct fees from the hospital/facility charges.

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

  • Total hospital billed charges: $390,789.00
  • ClaimDOC Pricing: $42,048.68 (Based on Medicare 2020 MS-DRG 455 with markup)
  • Plan Savings: $348,740.32
  • Percentage of Savings: 89%

The Takeaway

Over-inflated hospital charges were observed on the insurance claim and corresponding itemized bill (IB). While hospitals may charge any amount they elect for procedures/services performed, egregious fees 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 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.