Introduction and Episode Overview
[00:00:00] Stacey Richter: Episode 480. "Payment Integrity Meets Health System Boasts, Such as Our Rates Are 2x Medicare, and Carriers Who Also Have Medicare Advantage Contracts." Today I speak with Kimberly Carleson.
[00:00:32] Stacey Richter: You know that episode from this spring with Eric Bricker about stop-loss provisions as a way for some hospitals so inclined to make more money without technically at least raising rates like they can substantially increase the overall revenue from plan sponsors, the ones not paying attention at least, while still able to claim they are net net 0% increase or are very much still 2x Medicare, for example.
Well, today we stumble on a few more strategies to do the same thing in the show today with Kimberly Carleson. So spoiler alert.
To listen to this episode or read the show notes with mentioned links, visit the episode page.
Importance of Health System Billing Accuracy
[00:01:07] Stacey Richter: Now look, all this matters. It big time matters.
Anything that has to do with health systems and their billing of plan sponsors matters because as we have heard from multiple guests multiple times, the shows with Shawn Gremminger, Cora Opsahl, Claire Brockbank, Marilyn Bartlett, to name a few.
We have heard over and over again that usually almost 50% of plan sponsor costs have something to do with members going into the hospital and or getting care somewhere that is under a hospital's umbrella. 50%.
And today we learn that up to 80% of hospital bills may contain some error with 25 to 30% of those errors being significant. I just asked AI and it said that approximately five to 10% of total hospital spend by plan sponsors might be attributable to billing inaccuracies or excessive charges.
My guest today, as I have mentioned twice already, Kimberly Carleson also mentions a few stats about just the magnitude of some of these mistakes. I mean, five to 10% of 50% of total spend, is a lot of money.
Common Billing Errors in Health Systems
[00:02:11] Stacey Richter: Okay, so let's discuss what we discuss today, Kimberly Carleson and I. We start out kind of digging into the where, why, and how many of these errors come to be. Then we talk about some advice for those who work at health systems who may be interested for real in redressing some of the stuff that we discuss.
And this whole conversation, and also Kimberly's advice for health system leaders is particularly relevant for anybody looking to do direct contracting with plan sponsors, of course. Because yeah, with a carrier in the middle of some of this stuff, it might not be entirely clear to many plan sponsors, the magnitude or the member impact of these billing mistakes. However, in a direct contract? Yeah, expect eyes on. So it certainly would make good sense to get ahead of some of this stuff. As I don't know, I know nothing really.
But after talking to Kimberly and after talking with Dawn Cornelis a few years ago, for sure, some of this stuff can be chalked off to weird complexities and not repeatable kinds of excusable mistakes, but a good deal of it kind of seems like, how shall I say this? Preventable. It seems to fall into a category of why is this happening and it's pretty darn obvious it's a problem, and yet it still persists.
Advice for Plan Sponsors
[00:03:22] Stacey Richter: Where this conversation heads next is getting into advice for plan sponsors, which I will summarize for your convenience right now, and maybe add a couple of supplementary points.
Advice for plan sponsors that comes up in this conversation with Kimberly Carleson, number one, and this is a biggie, have a third party audit of claims. The point comes out pretty clearly in this show, but in that earlier episode I mentioned the one with Dawn Cornelis it also, this point comes out just as strongly.
And right now in the time-space continuum in 2025, I don't know how you could even argue with it, get a third party to audit your claims, who isn't owned by the same company as your ASO or TPA or whoever is processing the claims.
Julie Selesnick was on the pod last spring and in that episode she says, “Look, it is the very definition of a conflict of interest if you as a fiduciary hire somebody and expect them to accurately audit themselves.”
On this exact same topic in that recent Take Two episode with Justin Leader about The Mystery of the Weekly Claims Wire, he talks about an example where a TPA was using a branch of their own company to audit basically their own claims, and they found $21,000 in errors.
This wasn't even enough to cover the fee for finding those errors, which in this case was $25,000, right? They spent $25,000 to find $21,000 total. Meanwhile, the employer, they then got a third party in the mix who found all the actual errors, and it summed up to 20 times that. The third party auditor found over $400,000 in errors that they then recouped for the plan sponsor.
So yeah, first piece of advice for plan sponsors. Don't do that. Get a different payment integrity vendor. You need somebody else to audit claims other than the person who is doing the claims.
Second piece of advice that comes up in the conversation that follows with Kimberly Carleson, I'm just gonna give you the advice, but you need to listen to the show to get the real full gist of it.
Contract amendments that the TPA or ASO or health plan that they cannot negotiate to pay for charges that are not legally billable. Right. And this one is interesting for more than just payment integrity purposes. I'd say it's also interesting for direct contracting purposes and for TPA RFPs.
Again, Kimberly and I talk about this at some length, and the whole thing just reminded me of something that I had seen Dr. Cristin Dickerson write, she wrote, "It is not just about what percentage of Medicare is paid. It's about the codes charged. While an imaging center may charge one or two codes for an exam, I see hospitals charging eight codes. Those eight codes even paid at 200% of Medicare are ridiculous."
This is just also, if you start thinking about it, why you gotta watch it with those RBP contracts. And, Dr. Dickerson gives a really good example of even if you have an expert who limits code payments to some agreed upon amount, there are many cases where that just doesn't work and hospital billing systems are able to bypass the controls.
Now, what I just said is a little wonky. If you didn't understand it, do listen to the pod and then come back and you will totally understand it. But yeah, bottom line, don't accidentally agree to pay for stuff that should be free or shouldn't be billed for in the first place as per the law. That is piece of advice two that comes up in the conversation that follows.
And then piece of advice three is know your rights as a plan sponsor. There is the CAA, the Consolidated Appropriations Act. There is the no gag clauses rules. Plan sponsors have an absolute right to the itemized bill and they don't have to pay until they get one and it is deemed clean.
Plan sponsors have a right to the hospital contracts the TPA/ASO/health plan has negotiated. And look, having a right and actually getting those rates, which some deem a trade secret are two different things. So it is increasingly up to the plan sponsor to run a clean RFP, request for proposal, using best practices like Claire Brockbank talked about in that episode from last fall.
If an RFP bidder clearly admits they don't have transparent business processes, or they have all kinds of trade secrets that impede your access to transparent information, and if they don't seem to be so inclined to change, then it's on us really to exclude them from the RFP if they don't meet the terms.
Ann Lewandowski talked about this a little bit in the whistleblower episode from a few months ago, just how the Department of Labor definitely excuses ERISA plans during a contract period who are using a vendor who it turns out is not doing things as per ERISA requirements. But thaaat leeway ends at contract renewal.
Interview with Kimberly Carleson
[00:08:16] Stacey Richter: My guest today as aforementioned is Kimberly Carleson. She is the CEO of US Beacon, where the mission is to meticulously review and optimize medical bills.
My name is Stacey Richter. This podcast is sponsored by Aventria Health Group.
Kimberly Carleson, welcome to Relentless Health Value.
[00:08:34] Kimberly Carleson: It's a pleasure being here. Thank you for having me.
[00:08:36] Stacey Richter: What's the magnitude of the issues here? You, you know, just obviously for the members themselves, this can be a catastrophic situation, but if I'm thinking about this from the standpoint of the plan sponsor, what can you tell me about, you know, if I said, eh, is it worth it? What would you say?
[00:08:54] Kimberly Carleson: For an example, in a review from one client we have, there was 55,000 members. There's a $600 million medical spend. We had identified 64 million in excessive charges. That's more than 10% of the total spend, and that was just claims $10,000 and above.
[00:09:14] Stacey Richter: A lot of us sit in chairs and it's just like a million here, but $64 million.
[00:09:20] Kimberly Carleson: That's a lot of money.
[00:09:22] Stacey Richter: A lot of money. And that was in one year?
[00:09:23] Kimberly Carleson: One year. Mm-hmm.
Real-World Examples of Billing Errors
[00:09:24] Stacey Richter: So, what are the most prominent ways that a health system, a hospital, may wind up messing up a bill and overcharging?
[00:09:36] Kimberly Carleson: So I think you have documentation, delays or gaps. Physicians and clinicians may, they work under tight constraints, so documentation is delayed or incomplete.
Billing teams may make assumptions or apply standard charge protocols that don't reflect what actually occurred, and then you've got, your manual data injuries or your fat fingers that accidentally hit a button that they didn't mean to. It pulls the wrong code altogether, and so you're charged extra.
You've got unbundling services where some procedures may be billed in a bundled charge, and then on the itemized statement, they're billed separately. They pull out every single charge from that bundled charge.
You have upcoding. Codes are sometimes assigned to a higher level of complexity than what's medically necessary or documented?
There's duplicate billing charging for, non FDA approved items. We had a pacemaker one time that was non FDA approved, and you can't charge for that under CMS guidelines.
And then you've got inflated markups on routine items, time-based charges without time documentations like in ORs or recovery room, sometimes billing services that weren't even rendered.
And then I think you have the lack of coordination between departments because there's such a demand and the hospital systems are so packed and understaffed that there's lack of coordination. You have misuse of revenue codes, emergency room coding, details that are not properly done, and then repetitive charges on multiple days that they're in the hospital.
[00:11:04] Stacey Richter: So just kind of summing up what you, you said there, it sounds like. I think my big takeaway from everything you just said is that it could be one of many ways that this could happen. I mean, it could.
[00:11:15] Kimberly Carleson: That's just a few.
[00:11:16] Stacey Richter: Yeah. Yeah. It was a pretty, pretty comprehensive list. If that was just a couple of 'em. I'm getting the drift.
[00:11:53] Stacey Richter: So, as you said, it could be just simply fat fingers, just somebody messed up. It could be, it sounds like a failure to communicate adequately, maybe between like the clinical team and the billing team, so somebody makes an assumption that was not correct. The bundling errors we had Dawn Cornelis on several years ago, and this is one of the things that she talked about a lot, where, you know, if you're charging a bundled price, you can't then go back and charge for the individual services that are part of that bundle also.
You can just have duplicate billing, be it just a duplicate billing. Or it could be if it's an inpatient who's in the hospital for multiple days, they wind up charging for the same thing multiple days in a row. That should be one, as you said, time-based billing, you know, something was for like in an OR whatever, and that was not necessarily documented or is inaccurate in some way.
[00:12:47] Kimberly Carleson: I mean, I really don't think it's intentional. I think it's just sometimes I don't. Most of the time, I don't think it is, but it's just a lack of coordination between departments and just in a, everyone's in a hurry.
[00:12:56] Stacey Richter: Hospitals are large, really complicated entities with lots of stuff going on and lots of different people.
[00:13:03] Kimberly Carleson: And two, they change systems so much.
[00:13:05] Stacey Richter: And then I'm sure also from the clinical side, like as a clinician, you might not even realize what's being done with what you're typing in. Like you're trying to document what happened in the clinical visit and somebody else is gonna take that information and do other things with it, that now it's outside of your purview, what winds up happening down that particular vector stream.
But before, before we get, I definitely wanna ask you for some representative examples, maybe of all of this coming together in a way that is worthy of talking about on this podcast. But before we get there, let me ask you something. How do you know this? Like, are you actually talking to members and they say, no, I didn't have that in the ER.
Like, or whatever you know.
[00:13:52] Kimberly Carleson: Well, the coding guidelines, I mean, if you know your coding and you've been doing it long enough, you're aware of what can be charged. You're aware of someone goes into the ER for a stitch because they fell and bumped their head. They're not a level four ER visit. They're a one or two, you know, so you know from the medical records that this charge cannot be escalated up to a level four. So you just read the records.
[00:14:20] Stacey Richter: So it's not just, you know, they always say, you know, absolutely go and get an itemized bill. Like we've had Marshall Allen on the, like, you can practically talk to no one who won't tell you that the first thing that to do here with any sort of billing conundrum of almost any kind is to go get that itemized bill.
So can you just look at that itemized bill and see that what the severity is, or make some assumptions there? I mean, some of the stuff that you were talking about, definitely, like if it's a duplicate charge or whatever, if you get the itemized bill, you would be able to tell.
But some of the stuff relative to the severity of it, like wouldn't they just code that it was a level four trauma and not write down that it was one stitch.
[00:14:59] Kimberly Carleson: Right? You can absolutely see it from the itemized bill. The itemized bill's gonna tell you if they had Tylenol or if they had codeine. You know, it's going to tell you and you're gonna be able to see exactly what that patient went through at the time they were in the hospital.
[00:15:13] Stacey Richter: Let me just ask you for a couple of different examples here, and one of the reasons why I'm for sure digging in on this is just because we talk a lot on this podcast about how much plan sponsors tend to spend on hospital charges. You gave an example of a plan sponsor where almost 10% of charges were inaccurate and could be recouped.
So because the dollars are so big, errors can be huge. Can you just maybe run through just some real world examples of a situation that happened, just which may give listeners a little bit of context here.
[00:15:51] Kimberly Carleson: We had a lung transplant and it was out of network, but it was a single case agreement and it was 1.5 million was how much they were charging.
We were reviewing it and they charged $676,000 for the organ. You can't charge that for the organ. You have to charge 56,000. That's all, that is allowed by law. So once we got done with that bill, it went from 1.5 million to 290,000, and that's just ineligible charges. We just eliminate what legally should not be there.
From CMS guidelines, NCCI edits, NUBC, AMA, Social Security Act, all of those go into play with what we look at and it's just what legally is not owed.
[00:16:34] Stacey Richter: So someone was trying to charge $600,000 less for something that they should have charged 50 something. So it's like 10, 12 times what was allowable.
[00:16:45] Kimberly Carleson: Yes.
[00:16:45] Stacey Richter: So it's easy to see how these charges can just add up and it's, it was probably like their charge, master charge or whatever, and it almost sounds like the re-pricer like failed to notice this or whatever happened. But that bill made it all the way through the gauntlet and it was ready to be paid or already paid.
[00:17:04] Kimberly Carleson: I've seen implants be up to $30,000 when they should have cost 6,000. IV hydration therapy. That is a big one. You can't charge for saline in an IV that goes within the hospital charge. Operating room charges. I even saw the other day cutting a pill, a pill cutter. They charge like $20. That's just slicing the pill in half.
Your recovery room charges, they don't document the hours, so that can be extremely overcharged. Respiratory therapy services, if they're billed daily, it often lacks medical necessity or for provider information. You've got, oh, venipuncture when they put a needle into your arm. They can't charge you for the push of the needle, and they do that a lot.
The EKGs are well known for duplicate billing and charging excessively when they should be within the bundled code itself. Sterilization, I've seen it 19 times on a bill separated out, but sterilization is bundled in a code within the surgery. So that should never be separated.
Over the counter medication, that's not billable. It's not legally billable. You can't charge for Tylenol. Implant components. That's a huge one. They're all bundled into a code. You can't charge for each screw.
[00:18:17] Stacey Richter: Again, as we all know, and I think your examples indicate why it's so important to get the itemized bill
[00:18:24] Kimberly Carleson: Absolutely every time. You have to go back and ask for the itemized and sometimes they don't send it then. You have to, it's very difficult to get at times.
Legal Rights and Best Practices for Plan Sponsors
[00:18:33] Stacey Richter: As a plan sponsor, do I have a legal right to get the itemized bill or how does this work?
[00:18:37] Kimberly Carleson: Absolutely. You have a legal right under ERISA, the Consolidate Appropriations Act. You have a right to review your documents, itemized statement UB-04 before it's paid.
[00:18:47] Stacey Richter: But if they delay long enough, now all of a sudden my member's getting nasty grams. Like, how do you go about getting what you need while, meanwhile there's all this other, you know, I don't think the process probably stopped that the hospital just 'cause this is going on on the side.
[00:19:03] Kimberly Carleson: Legally by law allowed to have a review of your claim and you want a clean claim. Once you turn in a clean claim, then the 30 days for payment can go, the clock can start ticking for payment. We hound them with fax, emails, calling them in order to get that itemized statement. Most of the time a lot of hospitals are compliant. Most are, we know the ones that aren't.
[00:19:25] Stacey Richter: So how the process typically works is the plan sponsor is gonna go ask for the itemized bill. They may turn around and send you something else, like there's this UB-04 that gets brought up sometimes Autumn Yongchu talked about this just kind of general idea where there's itemized bills and then there's other documents that at the end of the day still are roll-ups that the hospital may respond with, which actually do not give enough information if you're trying to do a bill review.
So then you gotta turn around and say, no, no, no, no, no. I want the actual itemized bill. And you can cite the precedents for getting it. Do they have like a a period of time that they must send the itemized bill over in, or do you just say, you know, we ain't gonna pay it until you get me the itemized bill and therefore it's on them to choose how long they're gonna delay.
[00:20:13] Kimberly Carleson: Each state is different. We state those laws and we state how many days they have and the date. Usually you would have the allowable amounts, send it back, and that's what you pay. And typically, very few appeals when you do it right, when you, what's legally owed is paid.
[00:20:30] Stacey Richter: So if a plan sponsor is up on the regs and, and knows how much, what, you know, what the actual contractual allowable amounts are and a health system is told, look, this is the drill. This is what these charges should have been. Then they're not like in the meantime fighting with you while they're sending the member collection notices about the higher amount or something like that.
[00:20:51] Kimberly Carleson: Right. And so most don't allow that. As a bill reviewer, you let 'em know how, why you have did not allow those charges.
Give them the chapter number, give 'em the page number, whatever you have to do. I just got one the other day and I have to send back the chapter number of CMS guidelines, the page number of why this cannot be charged.
[00:21:10] Stacey Richter: But if you're a plan sponsor, what? What does CMS have to do with this?
[00:21:13] Kimberly Carleson: Those are the guidelines for billing.
The CMS guidelines is what you go off of the CPT codes. From the CMS, AMA, NCCI, all of those go into how much you're legally and contractually owe.
[00:21:25] Stacey Richter: Even as an ERISA plan?
[00:21:26] Kimberly Carleson: Yes, even as an ERISA plan. You cannot add the CPT code with another CPT code that is supposed to be all in the bundled CPT code.
Do you understand? You can't break certain CPT codes out if they're bundled into one.
[00:21:40] Stacey Richter: These are CMS regs. Like if you're charging a bundle payment, you can't just turn around and charge all the things that are actually part of the bundle also. There are other things, like you can't charge for sterilization multiple times.
You can't charge for pill splitting, you can't charge for venipuncture, right? Like these are all sort of part and parcel to what constitutes a code.
[00:22:00] Kimberly Carleson: There's federal guidelines for coding.
[00:22:02] Stacey Richter: Well, it's just interesting to me that some things do have those caps on them, like 60k for an organ.
[00:22:08] Kimberly Carleson: Well, and you know too, if a network has a contracted rate or a negotiated rate, there's nothing you can do about what is being charged.
If their contract says that they can charge for robotics, then they can charge for robotics. And you're not really allowed to charge for robotics because that's integral to the hospital equipment.
Billing can be so confusing, and I can understand how hospitals are perplexed when getting them out or making mistakes because it is very confusing and depending on the provider and plan you have.
[00:22:36] Stacey Richter: Also, are you saying that the lung transplant that wound up costing, you know, they were charging 600,000 for a lung when it should have been 50,000 for the lung.
Are you saying that sometimes, the carrier, whoever, there's another contract that would override that, those CMS guidelines. Right, so it could have been 600k if there there was a second agreement between whoever negotiated with the hospital.
[00:23:05] Kimberly Carleson: Absolutely.
[00:23:06] Stacey Richter: You're saying is in the absence of that, like if there is no contractually agreed upon number that was repriced in there or there's no line item for something, then CMS guidelines our enforce.
[00:23:20] Kimberly Carleson: Yes. For example, we were able to get a hold of a contract and they got to pay 29,000 for robotics. Well, robotics is not legally billable, but it's in the contract, so, the 29,000 stands.
[00:23:31] Stacey Richter: One of the things that does become clear is that there are incentives that carriers have, which may not always be aligned with their commercial customers, and this almost seems like another one of them where if the carriers trying to figure out how to get leverage to have a lower Medicare Advantage rate similarly to how they may do some of the stuff that we talked about in the show with Dr. Eric Bricker. They also could do this like, all right, well, we're gonna add another line item for robotics. We're gonna add another line item. So things that they were not previously able to charge for it's like the carrier can be like, all right, well, we'll do this for you.
Now all of a sudden, the hospital can increase their charges for things in ways that don't necessarily show up. And I'm saying this a little blindly, and if anybody knows the right answer, certainly let me know. But that's not gonna impact their, you know, their net net percent over Medicare, right?
Like they could still say, oh, we're 200% of Medicare overall, or whatever it is, because now they're charging for things that they previously weren't able to charge for. But maybe it's not 200% of Medicare. It should have been zero.
[00:24:41] Kimberly Carleson: It's very complex. When we review claims, we see in network 30% of ineligible charges, and that's after the discount.
Out of network we find 70% and above. And, so that is a significant amount of overspend in claims and that just trickles down to increasing your premiums, everything that would go within a self-insured plan.
Advice for Hospitals and Conclusion
[00:25:04] Stacey Richter: So what's your advice for hospitals? We've got lots of hospitals who would love to direct contract or work with plan sponsors. How do they get their billing up to the task?
Because, you'd think that any plan sponsor, savvy enough to direct contract, would also be savvy enough to have payment integrity review, and if it's Armageddon every time the plan needs to correct a wrong bill, that's not gonna be great for client relations or client retention.
So what, what do you think hospitals need to know about all of this?
[00:25:34] Kimberly Carleson: Let's designate a point of contact for review. Let's assign someone that's knowledgeable enough in compliance and billing to lead you and coordinate you directly to where you can go get those itemized statements. Then let's provide complete documentation without delay.
Let's provide the itemized statement, the UB-04, the medical records. Let's be proactive about providing those when asked for not continuing to prolong the process. Let's respond to the audit findings with openness. Let's when discrepancies are identified, nobody's trying to point fingers. We just wanna clean the bill so it can be paid.
So let's keep an open mind with it and, work with the company, review company that is reviewing the claims. And then I would just wish they would respect the legal rights of ERISA plans and the vendors to conduct audits and not use legal threats towards anyone that is trying to do the right thing to review the statements, to review the claims in order to fulfill their fiduciary duty.
So hopefully our findings would be quality improvement opportunity for hospitals.
[00:26:41] Stacey Richter: There's a lot of hospital executives that listen and it sounds like what you're saying is, I mean, it sounds reasonable to me, first of all, have a designated point of contact who knows who has been trained, which also could eliminate the last thing that you said is like, don't threaten things, which are not based on the law, right?
Then the second thing is when asked provide the documents, they're supposed to provide the documents, so provide them, respond quickly. I mean, this just seems like your average, normal customer service kind of stuff here. And then as you said, respect the legal right of vendors.
[00:27:18] Kimberly Carleson: But you know, if hospitals would look at it this way, when their compliance teams lean into accuracy and partnership, everyone wins.
It strengthens trust with payers and ensures patients and plans are only charged for what they actually need to pay for. And I think right now in healthcare, strengthening that trust is so important.
[00:27:38] Stacey Richter: Yeah. We just, we just literally did a show about the amount of distrust in the system and how just the number, it's over half of patients are scared to go to the hospital. They're delaying care because they're so worried that their bill is gonna bankrupt them or their family.
[00:27:56] Kimberly Carleson: You want the hospital to be paid. I'm all for the hospital being paid correctly and the plan paying what they owe. But when you start billing for things and negotiating secret contracts with carriers that involve charges that are not legally billable, that's where I have a problem.
[00:28:14] Stacey Richter: So what you're trying to do is go back then and say, look, I know you and the carrier cooked up a charge where you're allowed to charge for robotics, but you shouldn't be charging for robotics, so we're not gonna pay you for robotics. And they're coming back and saying, yeah, but I got a deal to charge for robotics. Like I got paper on that.
Therefore, we are gonna charge for robotics. Like that's when things get dicey.
[00:28:35] Kimberly Carleson: Exactly. Typically, you wouldn't mess with carrier rates, but if it's a charge that's not supposed to be billable, you shouldn't negotiate a rate and to charge it.
[00:28:44] Stacey Richter: So we have a few pieces of advice for hospital executives and finance teams that we just went through, mainly focused on assign a point of contact to work with plan sponsors or their vendors on billing questions and this point of contact should know the applicable laws and is customer service oriented.
Now we've pivoted into advice for plan sponsors, or I'm going to pivot us there, but with some amount of trepidation because I was gonna say, oh, first piece of advice is to make sure that your TPA or ASO or health plan isn't doing things where they get a better Medicare Advantage rate by agreeing that their commercial clients can get charged for stuff that CMS says you shouldn't get charged for.
But now I'm hesitant because given that these are secret deals between the carrier and the hospital, I am not sure how you would even know that the carrier health plan has negotiated with the hospital and included things that shouldn't be charged for until the plan sponsor got a bill for it, unless it's somehow, I don't know, somewhere in the carrier RFP, you say something like, here's a stipulation of this contract. All charges excluded by CMS will remain excluded. Like you actually put that in the RFP as a contract term.
[00:30:05] Kimberly Carleson: I would think so. I'm not real certain how that works, but I do know that as a plan sponsor, you should, you have a right to the contracts one, and you should, before you sign, look over your plan, detail your plan documents, and add in amendments or add in additions that say, we will not pay for charges that are not legally billable.
[00:30:27] Stacey Richter: As a plan sponsor, you stick a line in there that say, if you're not allowed to charge for it, we're not paying for it.
[00:30:32] Kimberly Carleson: We just not bill those things that aren't legally billable, and then no one will have a problem with it. So it would be really nice if that we could all come into compliance with what's legal and what's not.
[00:30:43] Stacey Richter: Okay. So we talked about a couple of different things to do proactively here. Is there anything else?
[00:30:50] Kimberly Carleson: I would assert your legal rights as a plan sponsor. You have the right to review itemized statement UP-04. You have the right to conduct pre and post payment reviews, and you have access to provider contracts with the no gag clause.
And then I would also partner with an independent review firm. If you get, if a plan tells you or a carrier tells you that they are reviewing your bills and they already have someone in house that's reviewing them for you, I would say I wanna bring in my own independent third party that doesn't have skin in the game.
[00:31:20] Stacey Richter: Recapping there, assert rights. Every plan sponsor has the right to review charges to review the itemized bill. Also access to the provider contracts vis-a-vis the no gag clauses. These things should be available. And then lastly, based on this conversation, I don't think there should be any question that it should be an indie bill reviewer.
Kimberly Carleson, thank you so much for being on Relentless Health Value today.
[00:31:46] Kimberly Carleson: Thank you for having me.
Closing Remarks and Call to Action
[00:31:47] Tom Nash: Hi, this is Tom Nash, one of the RHV team members. You might recognize my voice from the podcast intro. If you love the show and you wanna show us your support, please follow us on your favorite podcast app. Sign up for the newsletter, or maybe consider making a small donation in the tip jar. Thanks so much for listening.