Introduction: Medical billing can be a complex process, and it’s not uncommon for bills to be reviewed and repriced by multiple parties. However, when a national Managing General Underwriter (MGU) asked WellRithms to review an outpatient surgery bill of more than $500,000 that had already been repriced by a BUCA carrier, WellRithms discovered a number of concerning discrepancies. This case study will examine how WellRithms performed a line-by-line, chart-to-charge review and uncovered fraudulent billing practices in this case.
Background:
An outpatient surgery bill of more than $500,000 had already been repriced by a BUCA carrier to a contractual discount of 80% of billed charges. Two additional reviewers deemed this to be a “reasonable” payment. The national Managing General Underwriter (MGU) contacted WellRithms to perform a review of the bill.
The Case: WellRithms performed a line-by-line, chart-to-charge review of the bill and discovered that it included 14 procedures, all of which were individually coded. Several of the billed procedures were anatomically impossible given the patient’s prior surgeries and supporting diagnostic documentation. Furthermore, implants used in this surgery were billed at 10 times the average list price. WellRithms recommended a reimbursement closer to 20% of billed charges, based on their analysis of the bill and medical records.
The Reimbursement: Within six months of WellRithms’ review, the surgeon and his fiancée were found guilty of more than 200 counts of submitting false and fraudulent claims to Medicare and Medicaid. WellRithms’ analysis and recommendation of a lower reimbursement amount helped prevent this fraudulent billing practice from continuing unchecked.
Conclusion: WellRithms’ thorough review of an outpatient surgery bill of more than $500,000 uncovered fraudulent billing practices and helped prevent further abuse of the medical billing system. Their line-by-line, chart-to-charge review was able to uncover discrepancies that other reviewers had missed, and their recommendation of a lower reimbursement amount was ultimately proven correct. The case highlights the importance of careful and thorough review in preventing fraudulent billing practices in the medical industry.
