Audit Cases

Member Saves $3,817.09 After Surgery Bill Audit

With DirectAccess+, clients and members achieve maximum protection and savings. To establish savings information, ClaimDOC analyzes commercial contract pricing from data disclosed by hospitals and health plans. Utilizing the median commercially contracted price gives a fair estimate on the true savings being generated for the plan and the member. Licensed healthcare professionals conduct comprehensive line-by-line claim auditing to uncover errors typically not caught. Following are five recent audit results showcasing substantial savings.

1. Zephyrhills, Florida

One-day hospital stay for the treatment of spinal stenosis with related surgery.

Traditional Network Plan

  • Hospital Bill: $124,707.16
  • Median Commercially Contracted Price
    • $37,295.00
  • Patient Responsibility 20% Coinsurance:
    • $7,459.00

DirectAccess+

  • Hospital Bill: $124,707.16
  • ClaimDOC Allowable
    • $18,209.54
  • Patient Responsibility 20% Coinsurance:
    • $3,641.91
  • Plan Savings: $19,085.46
  • Member Savings: $3,817.09

2. Toledo, Ohio

Hospital outpatient services for the treatment of genetic susceptibility to ovarian cancer with related surgery.

Traditional Network Plan

  • Hospital Bill: $114,585.50
  • Median Commercially Contracted Price
    • $30,760.62
  • Patient Responsibility 20% Coinsurance:
    • $6,152.12

DirectAccess+

  • Hospital Bill: $114,585.50
  • ClaimDOC Allowable:
    • $11,676.39
  • Patient Responsibility 20% Coinsurance:
    • $2,335.28
  • Plan Savings: $19,084.23
  • Member Savings: $3,816.85

3. Tampa, Florida

One-day hospital stay for the treatment of hypertension urgency and obesity.

Traditional Network Plan

  • Hospital Bill: $50,063.20
  • Median Commercially Contracted Price
    • $15,404.50
  • Patient Responsibility 30% Coinsurance:
    • $4,621.35

DirectAccess+

  • Hospital Bill: $50,063.20
  • ClaimDOC Allowable:
    • $8,278.13
  • Patient Responsibility 20% Coinsurance:
    • $3,295.43
  • Plan Savings: $7,126.37
  • Member Savings: $2,137.91

4. Toledo, Ohio

Hospital outpatient services for the treatment of gastroenteritis, colitis and Crohn’s disease.

Traditional Network Plan

  • Hospital Bill: $107,057.70
  • Median Commercially Contracted Price
    • $18,418.33
  • Patient Responsibility 20% Coinsurance:
    • $3,683.67

DirectAccess+

  • Hospital Bill: $107,057.70
  • ClaimDOC Allowable:
    • $10,647.66
  • Patient Responsibility 20% Coinsurance:
    • $2,129.53
  • Plan Savings: $7,770.67
  • Member Savings: $1,554.13

5. Jacksonville, Florida

Seven-day hospital stay for the treatment of lung cancer and related surgery.

Traditional Network Plan

  • Hospital Bill: $81,052.49
  • Median Commercially Contracted Price
    • $34,576.10
  • Patient Responsibility 10% Coinsurance:
    • $3,457.61

 

DirectAccess+

  • Hospital Bill: $81,052.49
  • ClaimDOC Allowable:
    • $25,090.59
  • Patient Responsibility 10% coinsurance:
    • $1,312.40
  • Plan Savings: $9,485.51
  • Member Savings: $948.55

Disclaimer — The analysis of any medical billing or coding is dependent on numerous facts, regulations, payer policies and codes, as well as the controlling plan description. The information contained herein is intended to provide a real-life example of opportunities for savings through ClaimDOC services but is not intended to provide medical, legal or financial advice.