Federal law requires all employers to provide workers’ compensation benefits to injured workers, but it is up to each state to regulate how reimbursement is handled. Nearly all states have adopted a state-specific fee schedule. The remaining states opt to apply an open price term reimbursement approach known as Usual, Customary, and Reasonable (UCR). UCR reimbursement means the amount that is billed to the general public. UCR reimbursement utilizes any approach to a payment agreement that the payor and provider can agree to.
New Jersey is a UCR state. And when a $139,446 workers’ compensation bill from an orthopedic surgeon there arrived for WellRithms’ detailed review, our physician and surgeon review team found staggering unjustified charges for an orthopedic surgery. The surgeon performed multiple procedures during a single surgery, including:
- An open treatment for a left tibia (shin bone) fracture
- A meniscus repair (the meniscus is cartilage that acts as a shock absorber between the shinbone and the thighbone).
- The removal of an external fixation device that had previously been implanted.
- The suturing of a muscle.
Additionally, they charged for the use of fluoroscopy during the surgery, an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. This fluoroscopy charge was not warranted and thus not paid, after WellRithms’ review.
While all four surgical charges were allowed, WellRithms’ meticulous analysis and proprietary repricing methodologies revealed that the payment should be $9,053–just 6.5% of the billed total.
By leveraging our deep clinical expertise and robust review process, WellRithms significantly reduced the financial burden on the payor while ensuring that the medical providers received fair compensation. This careful repricing saved our client $130,392 exemplifying WellRithms’ commitment to fighting inflated medical bills and promoting transparency in healthcare reimbursement.
For more information on how WellRithms can help you navigate inflated medical bills, contact info@wellrithms.com.
