Introduction: Medical billing can be a complicated and contentious process, particularly when it comes to large hospital bills and stop loss carriers. When a TPA in Indiana found themselves facing such a situation, they turned to WellRithms for help. This case study will examine how WellRithms helped resolve a billing dispute and ensure an ongoing business relationship between the hospital and TPA.
Background: A TPA in Indiana was faced with a large hospital bill that their stop loss carrier was not willing to settle for the small discount offered by the hospital or the recommended payment from other reviewers. The TPA needed to determine a reasonable and customary price for the bill that would be acceptable to both the provider and the stop loss carrier. The hospital in question was also a customer of the TPA, adding an additional layer of complexity to the situation.
The Case: WellRithms was approached by the TPA to help resolve the billing dispute. WellRithms reviewed the bill, as well as eight boxes of medical records, and determined that approximately $250,000 of billed charges were coded erroneously using a code which is only billable and payable by Indiana Medicaid. None of the prior reviewers had noticed this discrepancy. When confronted, the hospital admitted to the billing “error” after WellRithms’ review.
The Reimbursement: WellRithms determined a reasonable price for the bill and facilitated an acceptable settlement for the stop-loss carrier. This allowed the hospital and TPA to maintain an ongoing business relationship.
WellRithms’ review and determination of a reasonable price were essential to resolving the billing dispute and ensuring a fair and acceptable settlement for all parties involved.
Conclusion: WellRithms was able to provide the expertise and knowledge necessary to resolve a complicated billing dispute involving a TPA and a hospital in Indiana. Their review and determination of a reasonable price, as well as their facilitation of an acceptable settlement, allowed the hospital and TPA to maintain an ongoing business relationship. The case highlights the importance of having experienced and knowledgeable experts in medical billing to ensure fair and accurate reimbursement.
