Audit Cases

Audit of Hospital Stay and Surgery Saves Member $10,391.10

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. Charleston, West Virginia

Fourteen-day hospital stay for the treatment of chronic left foot osteomyelitis and related surgery

Traditional Network Plan

  • Hospital Bill: $121,088.42
  • Median Commercially Contracted Price
    •  $88,964.09
  • Patient Responsibility 20% Coinsurance:
    •  $17,792.82

DirectAccess+

  • Hospital Bill: $121,088.42
  • ClaimDOC Allowable
    • $37,008.61
  • Patient Responsibility 20% Coinsurance:
    • $7,401.72
  • Plan Savings:   $51,955.48
  • Member Savings:  $10,391.10

2. Spartanburg, South Carolina

Six-day hospital stay for the treatment of pneumothorax and related surgery

Traditional Network Plan

  • Hospital Bill: $67,841.42
  • Median Commercially Contracted Price
    • $41,257
  • Patient Responsibility 20% Coinsurance:
    • $8,251.40

DirectAccess+

  • Hospital Bill: $67,841.42
  • ClaimDOC Allowable:
    • $16,641.86
  • Patient Responsibility 20% Coinsurance:
    • $3,328.37
  • Plan Savings: $24,615.14
  • Member Savings: $4,923.03

3. Orlando, Florida

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

Traditional Network Plan

  • Hospital Bill: $99,637
  • Median Commercially Contracted Price
    • $27,190.80
  • Patient Responsibility 20% Coinsurance:
    • $5,438.16

DirectAccess+

  • Hospital Bill: $99,637
  • ClaimDOC Allowable:
    • $14,780
  • Patient Responsibility 20% Coinsurance:
    • $2,956
  • Plan Savings: $12,410.80
  • Member Savings: $2,482.16

4. Houston, Texas

Seven-day hospital stay for the treatment of sepsis, diabetes and cellulitis right leg

Traditional Network Plan

  • Hospital Bill: $101,623.50
  • Median Commercially Contracted Price
    • $28,901
  • Patient Responsibility 20% Coinsurance:
    • $5,780.20

DirectAccess+

  • Hospital Bill: $101,623.50
  • ClaimDOC Allowable:
    • $20,643.14
  • Patient Responsibility 20% Coinsurance:
    • $4,128.63
  • Plan Savings:  $8,257.86
  • Member Savings: $1,651.57

5. Overland Park, Kansas

Five-day hospital stay for the treatment of heart disease and failure

Traditional Network Plan

  • Hospital Bill: $93,199.40
  • Median Commercially Contracted Price
    •  $14,967.25
  • Patient Responsibility 20% Coinsurance:
    •  $      2,993.45

 

DirectAccess+

  • Hospital Bill: $93,199.40
  • ClaimDOC Allowable:
    • $12,416.55
  • Patient Responsibility 20% coinsurance:
    • $2,483.31
  • Plan Savings:  $2,550.70
  • Member Savings: $510.14

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.