Red Flags Raise Questions: Egregious Charges or Billing Errors?
Background
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 its 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 Spotlight, we focus on two recent claims where the auditor’s eyes did a double-take, red flags went up and the question was asked – is the practitioner really charging this much for their service or is this a billing error?
Case Scenario 1
A 56-year-old plan member was seen in a Georgia ambulatory surgical center (ASC) setting for a screening colonoscopy test.
The CMS-1500 claim form/electronic equivalent was reported/ billed as follows:
- CPT code 00812 OX, QS, P2 – (one (1) unit) – service time of 34 minutes, and associated charge of $57,239.00
- CPT code 00812 is defined as, Anesthesia for screening colonoscopy.
Modifier OX depicts the service was performed by a certified registered nurse anesthetist (CRNA) without medical direction by a physician.
Modifier QS depicts monitored anesthesia care (MAC) services.
Modifier P2 depicts a patient with mild systemic disease.
Total Charge $57,239.00
ClaimDOC pricing $69.60 based on 2022 Medicare Physician Fee Schedule with markup
Plan Savings: $57,169.40
Percentage of Savings: 99.88%
Case Scenario 2
A 15-year-old plan member was seen in a Texas hospital outpatient setting for the treatment of a sprain of anterior cruciate ligament and lateral meniscus tear of the right knee and related surgery.
The CMS-1500 claim form/electronic equivalent was reported/ billed as follows:
- CPT code 29888, AS, RT and charge of $23,713.25
- CPT code 29882, AS, RT and charge of $16,784.25
- Total charges $40,497.50
CPT code 29888 is defined as, Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction.
CPT code 29882 is defined as, Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral).
Modifier AS depicts, an Assistant at Surgery Services provided by a physician’s assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS).
Modifier RT depicts, Right side.
Total Charge $40,497.50
ClaimDOC pricing $188.89 based on 2022 Medicare Physician Fee Schedule with markup
Plan Savings: $40,308.61
Percentage of Savings: 99.53%
The Takeaway
Concerns of egregious charges and/or billing errors were observed on the above two practitioner’s health insurance claims. While physicians/practitioners may charge any amount they elect for items/services provided, egregious fees and billing errors can complicate matters for members to understand their bills and payments, impact the collection of patient balances, build a reputation of facilities charging high fees, create burdens for patients having no insurance and a host of others.
While coding, billing and the reporting of healthcare services is a complicated process, simple billing errors include the submission of:
- Incorrect patient information
- Incorrect provider information
- Incorrect insurance provider information
- Incorrect CPT/HCPCS codes
- Incorrect modifiers
- Incorrect diagnosis(es) codes
- Incorrect quantity units
- Mismatched medical codes
- Leaving out codes altogether for procedures or diagnoses
- Duplicate billing
- Unbundling of services
- Erroneous charge(s) and
- Others
Whenever an individual receives a bill and the cost for care seems inappropriate/questionable, an inquiry to the provider and/or health plan should be made to obtain an explanation of the service(s) and corresponding charges.
Our goal at ClaimDOC is to use benchmark charges and costs nationally to negotiate fair and ethical payments. Employers turn to us 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.