The final total for implants was $2,747 a savings of nearly $16,000. Implants were only part of the $135,000 bill that was ultimately reduced to a recommended payment of $32,250.
Background
The cost of surgical implants has remained steady for the last four years with only slight fluctuations. Hospitals negotiate agreements with implant distributors for lower prices primarily based upon the volume used, much like Costco or other volume retailers. Such volume discounts are most common in total joint replacement, spine surgery, and trauma centers. This case is a perfect illustration of common charges for implants, and why it is vital for WellRithms clients to be certain that there is an expert doing the bill review.
The Patient
A 50-year-old woman suffered a fracture of her tibia (lower leg bone) and was admitted for surgical treatment of the fracture. Operative treatment of these fractures is the standard of care today. The patient underwent repair of the fracture, and the provider billed for 16 implants which totaled $11,304. Customary bill review would have re-priced these items at a percentage of billed charge, per their PPO contract. However, when WellRithms reviewed this particular bill, numerous irregularities were discovered.
The WellRithms Process
Utilizing medical expertise, WellRithms physicians read the operative report and compared this to the itemized billing statement. Of the 16 implants that were billed, five were used, six were used and removed, and five were billed as implants but were actually “supplies , not implants. It is important to note that when implants are discarded, dropped on the floor, broken while inserting, or used or removed during surgery, they are not eligible for reimbursement. Furthermore, other hardware such as drill bits and guidewires that were also used in this case are not implants by definition and cannot be billed as such.
The final total for implants was $2,747 a savings of nearly $16,000. Implants were only part of the $135,000 bill that was ultimately reduced to a recommended payment of $32,250.
Our Findings
| SUPPLIES BILLED AS IMPLANTS | Total Charges: $134,000 | |
| BILLED FOR DISCARDED IMPLANTS | | Recommended Allowance: $32,250 |
| EXCESSIVE CHARGES | | WellRithms Reductions: $101,750 |
The Bottom Line
Cost containment solutions such as network re-pricing or implant re-pricing would never include the medical expertise and surgical understanding necessary to read and interpret an operative report. In-depth bill review by a human being is essential to accurately pay for services rendered. Because WellRithms understands the specifics of the surgery performed and is able to distinguish implants from supplies, WellRithms recognized that more implants were discarded than were used and significant savings for our client were realized.
This detailed line by line bill review is the standard to which WellRithms adheres for each and every bill we review bringing guaranteed savings for our clients and payment integrity to the healthcare industry.
