Audit Cases May 27, 2025

Audit of Hospital Stay Saves Member $20,540.10

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. Orlando, Florida

Thirteen-day hospital stay for the treatment of cerebral infarction

Traditional Network Plan

  • Hospital Bill: $355,033.28
  • Median Commercially Contracted Price
    • $128,005.02
  • Patient Responsibility 30% Coinsurance:
    • $38,401.51

DirectAccess+

  • Hospital Bill: $355,033.28
  • ClaimDOC Allowable
    • $59,538.03
  • Patient Responsibility 30% Coinsurance:
    • $17,861.41
  • Plan Savings: $68,466.99
  • Member Savings:  $20,540.10

2. Phoenix, Arizona

One-day hospital stay for the treatment of complication of ventricular intracranial shunt and related surgery

Traditional Network Plan

  • Hospital Bill: $57,259
  • Median Commercially Contracted Price
    • $49,523.38
  • Patient Responsibility 20% Coinsurance:
    • $9,904.68

DirectAccess+

  • Hospital Bill: $57,259
  • ClaimDOC Allowable:
    • $10,010.86
  • Patient Responsibility 20% Coinsurance:
    • $2,002.17
  • Plan Savings: $39,512.52
  • Member Savings: $7,902.51

3. Troy, Michigan

Six-day hospital stay for the treatment of diverticulitis large intestine, perforation, abscess and related surgery

Traditional Network Plan

  • Hospital Bill: $112,847.67
  • Median Commercially Contracted Price
    • $56,621.61
  • Patient Responsibility 30% Coinsurance:
    • $16,986.48

DirectAccess+

  • Hospital Bill: $112,847.67
  • ClaimDOC Allowable:
    • $30,327.28
  • Patient Responsibility 30% Coinsurance:
    • $9,098.18
  • Plan Savings: $26,294.33
  • Member Savings: $7,888.30

4. Rock Hill, South Carolina

Nine-day hospital stay for the treatment of diabetes with gangrene and related surgery

Traditional Network Plan

  • Hospital Bill: $196,854.50
  • Median Commercially Contracted Price
    • $54,527.16
  • Patient Responsibility 20% Coinsurance:
    • $10,905.43

DirectAccess+

  • Hospital Bill: $196,854.50
  • ClaimDOC Allowable:
    • $24,801.18
  • Patient Responsibility 20% Coinsurance:
    • $4,960.24
  • Plan Savings: $29,725.98
  • Member Savings: $5,945.19

5. Snellville, Georgia

Four-day hospital stay for the treatment of hypertensive heart and chronic kidney disease with heart failure

Traditional Network Plan

  • Hospital Bill: $57,024.3
  • Median Commercially Contracted Price
    • $39,574.44
  • Patient Responsibility 20% Coinsurance:
    • $7,914.89

 

DirectAccess+

  • Hospital Bill: $57,024.3
  • ClaimDOC Allowable:
    • $13,750.55
  • Patient Responsibility 20% coinsurance:
    • $2,750.11
  • Plan Savings: $25,823.89
  • Member Savings: $5,164.78

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.