AUDIT SPOTLIGHT

Same Colonoscopy, Different Facilities, Wildly Different Costs

By Cynthia Swanson, RN, CPC, CEMC, CHC, CMPA, Senior Audit Manager

More than 16 million colonoscopies are performed in the United States each year. A common gastrointestinal procedure, colonoscopies are routinely performed as a screening for cancer, surveillance and as a diagnostic to evaluate symptoms. A colonoscopy is also one of the most frequently performed procedures in ambulatory surgery centers (ASC).

In this Audit Spotlight, we focus on routine screening colonoscopy services and the extreme differences in facility charges for this test.

Good TPAs – They Do Exist

Who’s a good third-party administrator? There are many to choose from, but far fewer that consistently deliver when it matters. And the difference between a good TPA and a mediocre one often determines whether a health plan works exceptionally well or frustrates everyone it touches.

Our last two episodes of ClaimTalk weren’t kind to TPAs. While much of that criticism was earned, the reality is that TPAs operate in a landscape that is complex, constrained and often misunderstood.

On this episode, Luke Schafer of BRMS joins Danielle Young, Shay Butler and Dallas Lovell to discuss why the strongest TPAs are the ones that stay in their lanes and are laser-focused on their primary responsibility — paying claims.

Watch the episode

Subscribe now so you never miss an episode:

Spotify

Apple Podcasts

YouTube

Allentown, Pennsylvania

Hospital Bill: $233,761.46

Five-day hospital stay for the delivery of a newborn by cesarian section with complications.

	Plan	Member
Traditional Network Plan	$121,310.01 Median Commercially Contracted Price	$24,262.00 Patient Responsibility (20% Coinsurance)
DirectAccess+	$71,271.45 ClaimDOC Allowable	$14,254.29 Patient Responsibility (20% Coinsurance)
Savings	$50,038.56	$10,007.71

Read more audit examples

To establish savings information, ClaimDOC analyzes commercial contract pricing from data disclosed by hospitals and health plans. The audit team performs line-by-line claim audits to help clients and members maximize their savings.

Service Shoutout

"I called in with a normal question — one that hundreds of our employees have — is my provider already in the club? Jessa offered to simply take on my issue herself rather than leave it in the queue. She walked me through the process all the way to the end. She was patient, encouraging and she communicated well."

AUDIT SPOTLIGHT﻿

Same Colonoscopy, Different Facilities, Wildly Different Costs

Good TPAs – They Do Exist

AUDIT SPOTLIGHT