Case Study 1

Claim Summary:

A PPO Member with Osteoporosis was referred to a laboratory for routine mammogram and preventative Dexa-scan by her physician. She received a bill from both the physician and the laboratory billing her over $800.


  • Reviewed Explanation of Benefits and medical bills and concluded physician had coded the bill incorrectly and carrier had misadjudicated claims.
  • Identified correct code. $400 was re-issued to providers.
  • Plus lab charges billed to patient were overcharged.
  • Compared contracted prices for procedure from other carriers in area.
  • Submitted appeal to the lab with appropriate documentation to adjust overage charges.

Money Saved:  $1,400