Audit Cases

Audit of heart attack treatment results in $2,950.53 member savings

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. Ocala, Florida

Two-day hospital stay for the treatment of heart attack and related procedure

Traditional Network Plan

  • Hospital Bill: $61,073.39
  • Median Commercially Contracted Price
    •  $18,595.84
  • Patient Responsibility 30% Coinsurance:
    •  $5,578.75

DirectAccess+

  • Hospital Bill: $61,073.39
  • ClaimDOC Allowable
    • $8,760.74
  • Patient Responsibility 30% Coinsurance:
    • $2,628.22
  • Plan Savings:  $9,835.10
  • Member Savings:  $2,950.53

2. Rock Hill, South Carolina

Eleven-day hospital stay for the treatment of diabetes and cellulitis of right toe

Traditional Network Plan

  • Hospital Bill: $173,105.00
  • Median Commercially Contracted Price $38,688.96
  • Patient Responsibility 10% Coinsurance: $3,868.90

DirectAccess+

  • Hospital Bill: $173,105.00
  • ClaimDOC Allowable:
    • $20,698.58
  • Patient Responsibility 10% Coinsurance:
    • $2,069.86
  • Plan Savings:  $17,990.38
  • Member Savings:  $1,799.04

3. Tyler, Texas

Two-day hospital stay for the treatment of spinal stenosis and related surgery

Traditional Network Plan

  • Hospital Bill: $72,878.50
  • Median Commercially Contracted Price
    •  $29,524.43
  • Patient Responsibility 20% Coinsurance:
    •  $5,904.89

DirectAccess+

  • Hospital Bill: $72,878.50
  • ClaimDOC Allowable:
    • $23,855.66
  • Patient Responsibility 20% Coinsurance:
    • $4,771.13
  • Plan Savings:  $5,668.77
  • Member Savings:  $1,133.75

4. Zephyrhills, Florida

Four-day hospital stay for the treatment of prolapsed hemorrhoids, hemorrhage and related surgery

Traditional Network Plan

  • Hospital Bill: $90,790.52
  • Median Commercially Contracted Price
    • $17,864.00
  • Patient Responsibility 20% Coinsurance:
    • $3,572.80

DirectAccess+

  • Hospital Bill: $90,790.52
  • ClaimDOC Allowable:
    • $12,695.95
  • Patient Responsibility 20% Coinsurance:
    • $2,539.19
  • Plan Savings:  $5,168.05
  • Member Savings:  $1,033.61

5. Davenport, Florida

Two-day hospital stay for the treatment of gallbladder stone and related surgery

Traditional Network Plan

  • Hospital Bill: $149,660.91
  • Median Commercially Contracted Price
    • $15,177.00
  • Patient Responsibility 20% Coinsurance:
    • $3,035.40

 

DirectAccess+

  • Hospital Bill: $149,660.91
  • ClaimDOC Allowable:
    • $10,425.10
  • Patient Responsibility 20% coinsurance:
    • $2,085.02
  • Plan Savings:  $4,751.90
  • Member Savings:  $950.38

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.