Audit Cases Apr 28, 2025

Audit of Hospital Stay and Procedure Saves Member $9,018.75

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. Hollywood, Florida

Three-day hospital stay for the treatment of inflammatory scrotal disorder and related procedure

Traditional Network Plan

  • Hospital Bill: $81,320
  • Median Commercially Contracted Price
    • $71,917.49
  • Patient Responsibility 20% Coinsurance:
    • $14,383.50

DirectAccess+

  • Hospital Bill: $81,320
  • ClaimDOC Allowable
    • $26,823.76
  • Patient Responsibility 20% Coinsurance:
    • $5,364.75
  • Plan Savings: $45,093.73
  • Member Savings:  $9,018.75

2. Omaha, Nebraska

Six-day hospital stay for the treatment of sepsis, heart and respiratory failure and other complications

Traditional Network Plan

  • Hospital Bill: $70,635.65
  • Median Commercially Contracted Price
    • $33,404
  • Patient Responsibility 30% Coinsurance:
    • $10,021.20

DirectAccess+

  • Hospital Bill: $70,635.65
  • ClaimDOC Allowable:
    • $20,498.29
  • Patient Responsibility 30% Coinsurance:
    • $6,149.49
  • Plan Savings: $12,905.71
  • Member Savings: $3,871.71

3. Freehold, New Jersey

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

Traditional Network Plan

  • Hospital Bill: $100,138.40
  • Median Commercially Contracted Price
    • $55,162.57
  • Patient Responsibility 20% Coinsurance:
    • $11,032.51

DirectAccess+

  • Hospital Bill: $100,138.40
  • ClaimDOC Allowable:
    • $37,486.21
  • Patient Responsibility 20% Coinsurance:
    • $7,497.24
  • Plan Savings: $17,676.36
  • Member Savings: $3,535.27

4. Somerville, New Jersey

Three-day hospital stay for the treatment of melena, dorsalis and acute posthemorrhagic anemia

Traditional Network Plan

  • Hospital Bill: $72,828.46
  • Median Commercially Contracted Price
    • $23,838.04
  • Patient Responsibility 20% Coinsurance:
    • $4,767.61

DirectAccess+

  • Hospital Bill: $72,828.46
  • ClaimDOC Allowable:
    • $11,855.44
  • Patient Responsibility 20% Coinsurance:
    • $2,371.09
  • Plan Savings: $11,982.60
  • Member Savings: $2,396.52

5. Panama City, Florida

Two-day hospital stay following cesarean section delivery

Traditional Network Plan

  • Hospital Bill: $57,894.75
  • Median Commercially Contracted Price
    • $14,449.41
  • Patient Responsibility 30% Coinsurance:
    • $4,334.82

 

DirectAccess+

  • Hospital Bill: $57,894.75
  • ClaimDOC Allowable:
    • $9,295.46
  • Patient Responsibility 30% coinsurance:
    • $2,788.64
  • Plan Savings: $5,153.95
  • Member Savings: $1,546.19

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.