Healthcare costs vary wildly depending on where you are, sometimes even within the same neighborhood. This disparity, often overlooked, fuels a system where egregious billing practices thrive. Combine this with factors like where a procedure takes place and the patient’s insurance status, and you have a recipe for potential abuse.
Unbundling Uncovered
This is exactly what happened in posh Beverly Hills where a private-practice surgeon sought to charge $114,100 for a hernia repair involving a middle-aged male whose health plan had a reputation for generous reimbursement. Given these circumstances, some medical practitioners cannot resist tacking on – and disguising – additional charges under unlisted CPT codes as part of a common practice known as “unbundling.”
A so-called “professional” bill that private practices such as the Beverly Hills clinic submit to insurance does not face the same scrutiny as bills from hospitals or ASCs, which must report cost-to-charge ratios and other pertinent information to CMS. That means they can pretty much charge whatever they want.
The bill in question included three surgeries: a laparoscopic repair of bilateral inguinal hernias billed at $68,000, an unlisted spermatic cord procedure billed at $15,000, and an umbilical hernia repair billed at $31,100. Our client denied the umbilical hernia repair for lack of preapproval and the unlisted code prior to review. Unlisted codes will sometimes get denied without supporting documentation, making the review of the operative report even more important.
A careful review of the operative notes determined that the removal of a lipoma (benign fatty ball) from the spermatic cord, which is part of the primary task, was disguised under an unlisted CPT code and, therefore, should not have been reimbursed. All of these charges were way beyond typical reimbursement for these procedures. WellRithms repriced the remaining bill of $68,000 for the inguinal hernia repairs at $1,406, which was just 1.2% of overall billed charges.
Our unique approach to repricing egregious claims incorporates a precise combination of standard payments, geographical and state-specific financial considerations, and inflationary adjustments. Together, the sum of these parts offers a true reflection of the complex economical terrain that shapes healthcare expenses.
For more information on how WellRithms can get you results, contact info@wellrithms.com.
