Poisonous Snake Venom Bite As Painful as Hospital Bill for Treatment
Background
ClaimDOC’s comprehensive line-by-line review 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, incorrect coding, 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 high dollar hospital charges for emergency outpatient services and antivenin treatment reported/billed on the UB-04 claim/electronic equivalent.
As healthcare costs continue to climb an upward slope, an escalated need exists for closer analysis of healthcare claims to identify egregious charges, improper medical coding and billing errors and associated improper claim payments.
Hospital Outpatient Emergency Services and Related Charges
A female was seen and treated at a North Carolina hospital emergency room for pain and swelling in the leg due to a venomous snake bite. It was determined antivenin was needed.
The hospital charged HCPCS code J0840 – CROFAB® (6 units) for $58,563.18. The hospital’s reported cost for the drug $11,466.67.
Member Claim
Hospital Outpatient Bill – Total Billed Charges $65,185.52
ClaimDOC pricing – $16,558.90 based on Medicare rate with markup
Plan Savings: $48,626.62
Percentage of Savings: 75%
The Takeaway
Additional doses of the antivenin may be administered as deemed necessary by the treating practitioner, based on the clinical course. As such, it is likely there will be subsequent hospital and practitioner charges for post bite care.
High dollar health care costs were identified on the above hospital outpatient claim. Egregious charges and the improper reporting of services, coding/billing errors can complicate matters for members to understand their bills and payments, impact the collection of patient balances, build a reputation of practitioners charging high fees, create burdens for patients having no insurance and a host of others.
Given the volume of healthcare claims that are reported/billed each day by providers/suppliers, medical bills errors and egregious charges are alarmingly common and lead to abuse, waste and fraud.
When an individual receives a healthcare bill that appears questionable/inappropriate, 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. Our high-quality and expert review of claims identifies and prevents improper medical claim payments and maximizes long-term cost savings opportunities. 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.