Real case. Real savings. Real impact.

The second hospital charged over $10,000 for the ER visit but never submitted the claim to insurance. They classified the patient as self-pay, leaving a balance of over $2,000, despite active commercial coverage.

Using the hospital's federally mandated price transparency data, we confirmed the insurer's negotiated rate was dramatically lower than the self-pay price. Once the claim is properly filed, the patient's OOP drops to a few hundred dollars.

The insurance carrier processed the admitting hospitalist's claim as out-of-network and paid nothing on it, a direct violation of the No Surprises Act (NSA), the 2022 federal law banning surprise medical bills at in-network facilities.

The NSA specifically protects hospitalists. Insurers must process these claims at in-network rates, and the protection is non-waivable under federal law. The insurer must reprocess the claim and pay its share.

The hospital billed a single CPT code three separate times on the same date of service. Coding guidelines dictate this specific code can only be billed once per day, so two of the three charges should not have been billed.

This is a widespread coding violation, and just one of many we catch routinely. Depending on the plan, the same error can cost patients and payers hundreds of dollars per occurrence.