Our Thoughts on Best Practices

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Claim of the Week: $424 Saved

August 2022
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Medical physician smiling at a patient

A 28-year-old patient presented to their physician with an alcohol dependency issue. Their plan would have paid $424, but after reviewing records, Nokomis found they were being charged for the incorrect level of service, ultimately saving the plan the entire $424.

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Claim of the Week: $1,107 Saved

August 2022
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Two doctors looking at an x-ray

A 43-year-old woman visited her oral surgeon’s office for a surgical procedure to remove and biopsy a tooth. Her health plan would have paid $2,014, but after reviewing records, Nokomis found that the documentation supported only one claim line, ultimately saving the plan $1,107. Medical record review matters and these claims might seem OK at…

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Claim of the Week: $5,270 Saved

July 2022
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A 52-year-old woman underwent gallbladder surgery. The plan would have paid $12,090; however, after reviewing records, we discovered that the documentation did not support the codes, ultimately saving $5,270.

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What are the results and outcomes of Claim Accountability?

July 2022
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Business woman sitting at desk on a laptop with Medicaid and Medicare binders

Payment integrity is an important part of the healthcare ecosystem. However, we’ve always believed in going beyond standard payment integrity. The healthcare claim submission process can be nuanced and complex, but it plays a vital role in outcomes for providers, payers, and patients alike. To amplify the impact of payment integrity, our team developed the…

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Claim of the Week: $17,160 Saved

July 2022
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A 43-year-old woman underwent back surgery to implant a spinal cord stimulator to alleviate her back pain. The plan would have paid $17,160, but further investigation uncovered that the documentation did not support the items in the claim. We recommended denying this claim, saving the plan $17,160.

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Claim of the Week: $4,860 Saved

July 2022
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A 56-year-old woman underwent surgery for a breast abscess. The plan would have paid $4,860. To avoid an NCCI edit, the provider submitted two claims instead of one, hoping that the plan wouldn’t catch the split bill. After reviewing the records, we denied both claims as neither code was supported.

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Claim of the Week: $7,566 Saved

July 2022
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A 20-year-old female presented to the ER with abdominal pain. Her health plan would have paid $11,936, but after reviewing records, Nokomis found that the listed provider was not the interpreting provider and had an inappropriate charge for IV fluids ($3,567). Ultimately, the health plan saved $7,566 after our review.

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ACAP Member Health Plans Tackle Large-Scale Re-Enrollment & Health Equity Priorities

July 2022
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Female healthcare worker filling in a form with a senior woman during a home health visit

Re-enrollment and social health equity are the focal points of community health plans across the United States as they tackle important hurdles to health for millions of the nation’s patients. With the end of the Public Health Emergency (PHE) looming on July 15th, even with a potential extension to October, Medicaid members could see a…

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Claim of the Week: $9,000 Saved

July 2022
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A 27-year-old male was treated in the emergency department for a laceration to his leg. His provider was ready to pay the claim, but Nokomis investigated the cause of the accident and discovered the injury happened on the job. The claim was denied and referred to the workers’ comp career for payment, saving the plan…

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Claim of the Week: $2,083 Saved

June 2022
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A 37-year-old woman presented at a free standing ER at 2:53am for treatment of a possible UTI which was evaluated with a dipstick urinalysis and treated with an oral medication. The patient was then discharged, 24 minutes later, at 3:17am. The plan would have paid $6,340. Nokomis obtained records and found that the provider billed…

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