Provider Quality Assurance/Member Protection

61 year old female spouse managed in the Clinic with chronic low back pain from disc disease who was receiving a series of therapeutic steroid injections from a reputable local pain clinic. During initial visit the patient received a urine screening for substances of abuse per pain clinic protocol but instead of the routine test an unwarranted battery was intentionally performed, which resulted in an unindicated $3,000 charge to the patient. The TPA was unable to help. She brought the issue to the Clinic when she was turned over to collections and serious attempts were made to collect by the physician.

Because of the claims registry, the Clinic was immediately able to determine that the TPA had paid the allowed charge for the appropriate test ($10) and correctly disallowed the remainder. The patient was the victim of a balance billing collection scheme going on in that clinic, and relief was found for her. More importantly, it was found that the same provider had done the same with two other Plan members in that year already. This led to the removal of said provider from the payer network. Subsequent forensic work by the Clinic looking for similar patterns throughout the Plan data revealed that another pain clinic had a similar scheme going that had targeted three other plan members, but with a much greater balance-billing exposure cost for the members totaling $75,000.

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