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.
Remediation:
- 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.