EP480: Payment Integrity Meets Health System Boasts, Such as Our Rates Are 2x Medicare, With Kimberly Carleson

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Jun 26, 2025

Kimberly Carleson, CEO of US Beacon, shares her expertise in payment integrity and the challenges of medical billing. She reveals the staggering prevalence of billing errors and their impact on healthcare costs. Kimberly emphasizes the necessity of third-party audits to catch inaccuracies and the importance of transparent communication in billing practices. She also discusses the rights of plan sponsors under various regulations and offers strategies for navigating complex medical billing systems, ultimately advocating for fairer costs and enhanced compliance.

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INSIGHT

Hospital Billing Error Magnitude

Up to 80% of hospital bills contain errors, with 25-30% being significant. 5-10% of total hospital spend may result from billing inaccuracies or excessive charges.

ADVICE

Use Independent Claims Auditors

Plan sponsors must engage an independent third-party to audit claims without conflicts of interest. Avoid using auditors owned by your own TPA or claims processor.

ADVICE

Exclude Non-Legally Billable Charges

Ensure contracts explicitly exclude payment for charges that are not legally billable. Carefully scrutinize bundled codes and separate charges to avoid overpayment.

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Enhancing Payment Integrity in Health Systems: An In-depth Discussion with Kimberly Carleson.

In Episode 481 of Relentless Health Value, host Stacey Richter speaks with Kimberly Carleson, CEO of US Beacon, about payment integrity within health systems. They delve into strategies some hospitals use to maximize revenue without raising rates and discuss the importance of accurate billing.

Key takeaways include the high prevalence of billing errors, which can lead to significant overcharges for plan sponsors, often due to documentation gaps and complex coding systems. Kimberly provides actionable advice for both healthcare providers and plan sponsors on how to mitigate billing inaccuracies and enhance transparency.

Emphasized points include the necessity of third-party claim audits, understanding legal rights under various acts, and the importance of maintaining clear communication and compliance with legal billing standards.

=== LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP480

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28:44 Advice for hospital executives and their finance teams.

29:03 Advice for plan sponsors.