Case Studies

Issue

Two identical charges for the same ER evaluation code on the same date. Additionally, the room charge was 3.1x the regional benchmark.

Action Taken

Dispute letter sent via fax citing duplicate billing and benchmark comparison. Follow-up call at day 7.

Outcome

Hospital removed the duplicate charge and reduced the room rate. Total bill reduced by $1,680.

Issue

Three procedure codes billed separately that should have been bundled under a single surgical code per NCCI rules.

Action Taken

Dispute filed via fax and certified mail with NCCI edit pair documentation.

Outcome

Provider acknowledged the coding error and reprocessed the claim. Patient refunded $2,340.

Issue

IV saline and acetaminophen charged at 15x and 28x retail pharmacy prices respectively.

Action Taken

Dispute letter with NADAC price comparison for each medication.

Outcome

Hospital adjusted pharmacy charges to 3x NADAC, reducing the bill by $890.

Issue

Billed as a Level 5 evaluation (99215) for what documentation suggests was a Level 3 visit.

Action Taken

Dispute filed citing E/M code level guidelines and documentation requirements.

Outcome

Provider downgraded to Level 3 and refunded the difference of $620.

Issue

Comprehensive metabolic panel and CBC billed at 8x the Clinical Lab Fee Schedule rate.

Action Taken

Dispute with CLFS benchmark comparison sent via fax. Escalated to certified mail after no response at day 14.

Outcome

After escalation, hospital reduced lab charges to 2x CLFS. Savings of $1,450.