Audit Cases

Member Saves $14,046.68 After Audit of Hospital Stay

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. Spartanburg, South Carolina

Eleven-day hospital stay for the treatment of heart attack and related procedures

Traditional Network Plan

  • Hospital Bill: $304,489.61
  • Median Commercially Contracted Price
    •  $137,778.61
  • Patient Responsibility 20% Coinsurance:
    •  $27,555.72

DirectAccess+

  • Hospital Bill: $304,489.61
  • ClaimDOC Allowable
    •  $67,545.22
  • Patient Responsibility 20% Coinsurance:
    • $13,509.04
  • Plan Savings:  $70,233.39
  • Member Savings:  $14,046.68

2. Ocoee, Florida

Two-day hospital stay for the treatment of immune thrombocytopenic purpura

Traditional Network Plan

  • Hospital Bill:  $206,091
  • Median Commercially Contracted Price
    • $43,195.03
  • Patient Responsibility 20% Coinsurance:  
    • $8,639.01

DirectAccess+

  • Hospital Bill:  $206,091
  • ClaimDOC Allowable:
    •  $18,129.96
  • Patient Responsibility 20% Coinsurance:
    • $3,625.99
  • Plan Savings:  $25,065.07
  • Member Savings:  $5,013.02

3. Lakeland, Florida

Three-day hospital stay for the treatment of stroke

Traditional Network Plan

  • Hospital Bill:  $93,928.82
  • Median Commercially Contracted Price
    •  $27,707.71
  • Patient Responsibility 20% Coinsurance:
    •  $5,541.54

DirectAccess+

  • Hospital Bill:  $93,928.82
  • ClaimDOC Allowable:
    •  $18,415.26
  • Patient Responsibility 20% Coinsurance:
    • $3,683.05
  • Plan Savings:  $9,292.45
  • Member Savings:  $1,858.49

4. Toledo, Ohio

Seven-day hospital stay for the treatment of heart and respiratory failure

Traditional Network Plan

  • Hospital Bill:  $94,665.50
  • Median Commercially Contracted Price
    •  $18,379.06
  • Patient Responsibility 20% Coinsurance:
    •  $5,513.72

DirectAccess+

  • Hospital Bill:  $94,665.50
  • ClaimDOC Allowable:
    •  $13,740
  • Patient Responsibility 30% Coinsurance:
    • $4,122
  • Plan Savings:  $4,639.06
  • Member Savings:  $1,391.72

5. Elgin, Illinois

Seven-day hospital stay for the treatment of atherosclerotic heart disease and related surgery

Traditional Network Plan

  • Hospital Bill:  $220,582.33
  • Median Commercially Contracted Price
    •  $59,693.97
  • Patient Responsibility 20% Coinsurance:
    •  $11,938.79

 

DirectAccess+

  • Hospital Bill:  $220,582.33
  • ClaimDOC Allowable:
    •  $54,944.05
  • Patient Responsibility 20% coinsurance:
    • $10,988.81
  • Plan Savings:  $4,749.92
  • Member Savings:  $949.98

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.