Medical Bill Audit
Findings Report

Patient (Fictional)

Jordan M. Sample

Billing Episode

ED Visit + Observation Stay

Facility (Fictional)

Riverton General Hospital

Date of Service

March 12, 2026

Audit Completed

March 21, 2026

Auditor

BOOJEE Bill Audit Team

1. Episode Summary

Visit type: Emergency department presentation, transitioned to observation status, discharged same day
Chief complaint: Chest pain, shortness of breath (per client-provided intake notes)
Documents reviewed: Itemized hospital bill (3 pages, 28 line items); EOB from Blue Shield Plan (fictional), received March 18, 2026; anesthesia bill from Riverton Anesthesia Group (separate provider)
Total billed (all providers): $8,742.00
EOB: insurer allowed amount: $4,318.00
EOB: patient responsibility: $1,204.00 (after deductible and co-insurance per EOB)
Items flagged for review: 4 findings (2 HIGH priority, 1 MEDIUM, 1 INFO)

2. Line-Item Findings

The table below lists each finding in priority order. Line items not listed had no apparent discrepancy relative to the EOB and the described services.

Line / CPT	Description (as billed)	Billed Amount	Issue Found	Priority	Potential Adjustment
`99285`	ED E&M Visit, Level 5	$2,480.00	Billed at Level 5 (highest complexity). Client intake notes describe a standard cardiac workup with normal EKG results and no acute findings. Level 5 requires either a high-complexity medical decision or a presenting condition posing threat to life. Clinical notes not available to us, but the described visit warrants requesting documentation of the medical-decision-making rationale. This is a signal for upcoding inquiry — not a confirmed error.	HIGH	Level 4 reimbursement typically runs $600–$900 lower than Level 5 in this region. Inquiry recommended.
Line 7 & Line 14	Cardiac Monitoring — Continuous (Line 7) Cardiac Monitoring — Telemetry (Line 14)	$480.00 × 2 = $960.00	Two separate cardiac monitoring charges appear on the bill for the same date and time range (18:30–23:15). "Continuous cardiac monitoring" and "telemetry" describe the same service and should not be billed separately for the same episode duration. This is a clear duplicate-charge pattern.	HIGH	$480.00 — one charge should be removed
`36415`	Venipuncture — routine	$68.00	EOB shows this charge was denied by the insurer as bundled into the ED facility fee. Insurer has already excluded this from patient responsibility. However, the hospital bill still shows $68.00 as patient-owed. This is a balance-billing discrepancy: the provider appears to be billing the patient for a charge the insurer has already disallowed.	MEDIUM	$68.00 — should not appear as patient-owed per EOB
Anesthesia bill, Line 1	Anesthesia services — Riverton Anesthesia Group	$1,240.00	Riverton Anesthesia Group is listed as out-of-network on the EOB. This was an ED visit at an in-network hospital. Under the No Surprises Act (effective Jan 1, 2022), patients cannot be charged more than in-network cost-sharing for emergency services, even if the provider is out-of-network. The facility is in-network; the service was emergency care. This warrants an NSA-based dispute. Note: the NSA has specific dispute procedures; your dispute letter should reference 42 U.S.C. § 300gg-111.	MEDIUM	NSA limits patient cost to in-network co-insurance rate. Estimated reduction: $680–$900 depending on plan terms.
Hospital Account	Financial assistance eligibility	N/A	Riverton General Hospital (fictional) is a nonprofit facility and is required under Section 501(r) of the Internal Revenue Code to offer a financial assistance policy (FAP). The bill contains no disclosure of this program. If the client's household income falls below 200–400% of the federal poverty level (thresholds vary by hospital), the bill may be eligible for significant reduction or elimination under the FAP. An itemized-bill letter and FAP application are included in the letter drafts.	INFO	Up to 100% of balance, depending on income and hospital policy.

3. Savings-Opportunity Summary

Duplicate cardiac monitoring charge (confirmed) $480.00

Balance-billing discrepancy — venipuncture (per EOB) $68.00

ED Level 5 upcoding inquiry (estimated reduction if adjusted to Level 4) $600–$900

No Surprises Act — anesthesia out-of-network (estimated) $680–$900

Documented + potential total $1,828–$2,348

The $480 duplicate charge and $68 EOB discrepancy are the most straightforward findings — these are documented on paper and do not require clinical records to dispute. The Level 5 upcoding and NSA claims depend on provider response and may require additional documentation. Savings figures are estimates only. No outcome is guaranteed.

4. Dispute Letter Draft — Billing Department

This is a ready-to-send draft addressing the two highest-priority findings: the duplicate cardiac monitoring charge and the venipuncture balance-billing discrepancy. Review, personalize the bracketed fields, and send on your own letterhead or by certified mail. Additional letters for the Level 5 upcoding inquiry, the No Surprises Act anesthesia dispute, and the financial assistance application are included in your full delivery package (not shown in this sample).

To: Riverton General Hospital — Patient Billing Department
Via: Certified mail + email to billing@rivertongeneral-fictional.example
Re: Billing Dispute — Account [YOUR ACCOUNT NUMBER] — Date of Service March 12, 2026

[YOUR NAME] [YOUR ADDRESS] [YOUR CITY, STATE, ZIP] [DATE] Riverton General Hospital Attn: Patient Billing Department [HOSPITAL ADDRESS] Re: Billing Dispute — Account [YOUR ACCOUNT NUMBER] Date of Service: March 12, 2026 To Whom It May Concern, I am writing to formally dispute two charges on my account for the above-referenced date of service. --- FINDING 1: DUPLICATE CHARGE — CARDIAC MONITORING My itemized bill (a copy of which I have enclosed) shows two separate charges for cardiac monitoring during the same time period: Line 7: Cardiac Monitoring — Continuous $480.00 (18:30–23:15) Line 14: Cardiac Monitoring — Telemetry $480.00 (18:30–23:15) These two charges describe the same service over the same time window. Continuous cardiac monitoring and telemetry monitoring are not separately billable for the same time period; they represent the same clinical activity under different names. I am requesting that one of these duplicate charges — $480.00 — be removed from my account. --- FINDING 2: BALANCE-BILLING DISCREPANCY — VENIPUNCTURE My Explanation of Benefits (EOB) from [YOUR INSURER], dated March 18, 2026 (enclosed), shows that the venipuncture charge (CPT 36415, $68.00) was denied as bundled into the ED facility fee. My insurer has therefore excluded this charge from my patient responsibility. However, my hospital bill continues to list $68.00 as amount due from me. I am requesting that this charge be removed from my patient balance, consistent with my insurer's determination. --- REQUESTED ACTIONS 1. Remove one duplicate cardiac monitoring charge — $480.00 — from my account. 2. Remove the venipuncture charge — $68.00 — from my patient balance, consistent with my EOB. 3. Confirm in writing (by mail or email) that these adjustments have been applied to my account. I am prepared to cooperate with any verification process you require. Please do not send this account to collections while this dispute is under review. If you need to reach me, my contact information is: Name: [YOUR NAME] Phone: [YOUR PHONE] Email: [YOUR EMAIL] Date of birth: [MM/DD/YYYY] Thank you for your prompt attention. Sincerely, [YOUR SIGNATURE] [YOUR PRINTED NAME] [DATE] Enclosures: - Copy of itemized bill (3 pages) - Copy of EOB from [YOUR INSURER], dated March 18, 2026

5. Next Steps

Send the billing department dispute letter first (Letter 1, included above). Address the duplicate charge and balance-billing discrepancy. These are the most document-supported findings and the most likely to result in a quick adjustment. Send by certified mail; keep your tracking number.
Send the Level 5 upcoding inquiry letter (Letter 2, in your full delivery package). Request a copy of the medical-decision-making documentation supporting the Level 5 code. This is your right as a patient. If the documentation does not support it, request a downcode adjustment.
Send the No Surprises Act dispute to the anesthesia group (Letter 3, in your full delivery package). Reference 42 U.S.C. § 300gg-111. If the anesthesia group does not resolve it, file a complaint with the Centers for Medicare & Medicaid Services (CMS) at cms.gov/nosurprises.
Request the hospital's financial assistance application (Letter 4, in your full delivery package). Nonprofit hospitals are required to provide this. Even if your income is moderate, it is worth applying — thresholds can be generous (up to 400% FPL at some hospitals). This can run in parallel with the billing dispute.
Document everything and keep copies. Note the date each letter was sent and by what method. Keep every written response you receive. If the billing dispute is not resolved in 30 days, call the billing department to confirm receipt and note the representative's name, date, and call summary.

This is a SAMPLE report using entirely fictional data. Jordan M. Sample, Riverton General Hospital, and all figures, codes, and account details are fabricated for illustration purposes only. A real BOOJEE Bill Audit report is based solely on the actual documents you provide. No outcome is guaranteed. This report is not medical, legal, or insurance advice. BOOJEE Bill Audit is a document review service — we are reviewers you choose to share your documents with, not your attorney, insurer, or medical provider.

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