FREQUENTLY ASKED QUESTIONS
EDITS, & AUDIT
Medical claims and bills are riddled with errors. WellRithms' CEA scrubs each bills to ensure accuracy.
What percentage of medical bills contain errors?
90% of medical bills contain errors (Becker's Hospital Review).
How does WellRithms detect medical billing errors and what processes prevent these errors from influencing reimbursement recommendations?
WellRithms has built classification algorithms into its proprietary software so that the errors outlined above are detected and corrected prior to a physician review of the medical records. Furthermore, standard industry accepted edits, such a CCI (Correct Coding Initiative), are applied prior to repricing. If an individual provider is known for a specific type of upcoding, this will be flagged in our system for all future bills and repriced appropriately. Our algorithms are architected to find questionable, abusive, and fraudulent charges and is continually tuned and updated to catch and flag suspicious charges for physician review.
What are some examples of errors that WellRithms commonly identifies?
WellRithms has found one of the most common errors on a bill is inaccurate Place of Service (POS). Misidentifying an Ambulatory Surgery Center (ASC) as a hospital, or a doctor’s office as a surgery center, can greatly influence the reimbursement. WellRithms has found this to be the most common error on a bill. It is important to understand that repricing a claim through a PPO, RBP, or another cost containment strategy will not identify this error thus resulting in significant overpayment.
Another common error is found through a disparity between the medical records and the billing statement:
Services added that were never performed
Implant devices billed that were never used
Severity levels that have been inflated
Bundled codes billed separately (sometimes on an entirely separate bill to fly under the radar)
Services billed that are not medically appropriate for the diagnosis and procedures provided
Grossly inflated provider charges/costs in comparison to what they have reported to the government
Drug choices and costs
Supplies used and costs
Implant appropriateness and costs
Excessive charges in surgery
Who is reviewing my medical bill today?
If WellRithms is not reviewing your bills, likely no one.
While state fee schedules and traditional bill review systems are designed to identify clinical edits, unbundling tricks, and medically unlikely edits, they are not equipped to anticipate creative billing schemes. Comprehensive bill review is not viewed as an essential component of claims processing or PPO network reductions.
Nurses may review certain cases, looking at the overall diagnosis and treatment, but this only scratches the surface on the amount of errors, abusive billing practices, and fraudulent activity that can be buried in a bill.
The validity of charges is paramount to any defense of the bill and significantly influences any balance billing.
& BILL PRICING
In addition to errors on medical bills, charges are often inflated. WellRithms' repricing methodology is fair for providers and payers.
What type of medical bills does WellRithms review and reprice?
WellRithms reviews and reprices all inpatient hospital bills, out patient hospital bills, ambulatory surgery center bills and professional bills. We do not reprice any dental or out patient pharmacy bills.
How does WellRithms’ Sustainable Claim Repricing differ from its medical bill review audit?
Our medical bill review audit is designed to “clean” the medical bill from any errors, abusive billing practices or fraudulent activity. WellRithms’ Sustainable Claim Repricing reviews the bill to adjust & correct excessive charges. We strongly believe that providers should be paid a fair and reasonable amount (that includes a profit) for the work that they do. Sadly, most billing statements are not initially invoiced at a fair and reasonable amount.
If a doctor or a nurse administered a dose of medicine that was 2,350 times the prescribed dosage, what would happen to the patient? Translate this example to billing. We regularly come across billing statements with this type of egregious markup from the providers’ reported costs.
"We believe claim care is as important as patient care."
- Anna Quarum, Chief Operating Officer
"At WellRithms we don’t do things the easy way, we do things the right way."
- Jordan Weintraub, Vice President, Claims
What data sources does WellRithms use to determine its recommended reimbursement.
WellRithms reference rate is based upon the English common law principle of quantum meruit, which has been confirmed under the Uniform Commercial Code as appropriate for determining a reasonable price in an open price term contract. In support of quantum meruit, the Arizona Supreme Court affirmed a lower court’s decision on appeal and determined reasonable reimbursement as what a provider normally accepts as payment for services. Dr. Merrit Quarum’s previous company, Qmedtrix, represented the defendant in this case. Both a Medicare multiple and an overall average cost-to-charge ratio are statistical. These methodologies apply to a group of bills rather than a specific bill. Thus, using a Medicare multiple and/or an overall cost-to-charge ratio as a reference is arbitrary and difficult, if not impossible, to defend.
The basis for WellRithms methodology is the most recent publicly available Medicare cost report submitted by hospitals. The WellRithms methodology is complex beginning with the fact that the cost centers found in Medicare cost reports do not directly correlate with revenue codes on a bill. While crosswalks between cost-to-charge ratios and the revenue codes are available, they are 50% incomplete. WellRithms has every publicly available Medicare cost report loaded in its system and has developed a proprietary and comprehensive crosswalk between every individual departmental cost-to-charge ratio and every revenue code that may appear on a bill. Individual cost-to-charge ratios are variably increased based on geographic factors and a facility’s reported acceptable reimbursement rates. Rather than using a single reference rate, WellRithms methodology utilizes all these factors when determining an accurate usual, customary, and reasonable price for a bill.
Do you apply the same repricing methodology for all types of services and in all jurisdictions?
WellRithms reviews medical bills across all insurance industry lines, including Commercial Health, Worker’s Compensation, Automobile Accident, and Liability. Each insurance line is regulated uniquely and must be considered when reviewing a bill. However, the overall legal principal of quantum meruit is the driving force behind all of our work.
All bill review clinical edits are specific to each bill type but are consistent for all jurisdictions and include a physician review of the services to ensure that the bill matches the medical records.
Our reimbursement determination, after bill review is performed, is calculated based on reported data from government, private payer, commercial, and specific cost data for each medical procedure within a specific facility.
What is this “quantum meruit” that you keep mentioning?
What is the turnaround time for WellRithms to review and reprice a medical bill?
Most medical bills are reviewed and repriced within 24-48 hours. Should our team require additional time to review lengthy medical records, we will notify the appropriate party of an ETA.
What is your average savings on a medical bill that is reviewed?
Our average savings vary from state to state, by specialty, and by insurance industry. Nationally for all bill types, WellRithms experiences an average to 60% to 80% in savings from the amount billed by providers. This reduction is GUARANTEED. All bills have been carefully reviewed and prepared for a legal defense before it leaves our office. WellRithms stands by its price, successfully removing all errors, excessive charges, and abusive or fraudulent billing practices. Should a provider disagree with our recommended reimbursement, WellRithms fully supports and defends its reimbursement.
Should a provider disagree with the WellRithms reimbursement amount, does WellRithms negotiate settlements to resolve pricing disputes?
WellRithms does not negotiate with providers on any pricing disputes. WellRithms engages with providers to explain the reimbursement methodology that was utilized to determine fair reimbursement. WellRithms expects the provider to offer the same courtesy by supplying a detailed explanation of their dispute with documentation that justifies additional payment. Should a provider substantiate additional justifiable reimbursement by submitting documentation that supports services performed but not paid, WellRithms will review and make sure the provider is paid on all services performed. However, if a provider simply wants more money for services already reimbursed, they must explain how their reported costs (and a profit) are not met.
What is the legal defense process that WellRithms utilizes?
The defense process varies depending on the jurisdiction of the claim state. WellRithms will provide legal support including exhibits and expert witness testimony and defense using WellRithms appointed counsel on all correspondence surrounding a medical appeal, dispute, or hearing. WellRithms will respond to all provider fee dispute applications and/or petitions according to the appropriate state mandated timeline requirements and always copy the adjuster or the appropriate customer representative on all correspondence. Legal expenses for filing of a petition or dispute application fees are at the expense of WellRithms. WellRithms will correspond regularly with the adjustor or appropriate representative on cases that should be considered for Shield Indemnification services.
Does WellRithms pick up all defense costs associated with defending its pricing? Do you also cover any penalty and interest cost associated with your pricing? Is there a cap on defense costs per bill, or per customer?
For Sustainable Claim Pricing bill review, WellRithms will provide legal defense using WellRithms approved and appointed legal counsel throughout the litigation process to defend our pricing. Should a client decide to choose their own legal counsel, WellRithms will provide legal exhibits and expert witness services only.
Under the WellRithms Shield Indemnification service, WellRithms assumes all defense costs (without cap) as well as any penalty, interest, or adverse judgement money owed back to the provider.
What legal challenges has WellRithms encountered regarding its reimbursement methodology and the outcomes?
Our methodology is supported by case law and favorable decisions across the nation, most significantly: Canyon Surgery Center vs. SCF Arizona (2011), affirmed by the Supreme Court, as well as the following en banc decisions in California: Kunz vs. Golden Eagle (2002), Tapia vs Liberty Mutual (2008).
WellRithms Shield is designed to indemnify our clients from claims and bills that significantly impact their budget.
How does WellRithms assume all responsibility and legal liability for claims that are assigned to WellRithms Shield Indemnification?
Not all medical bills require Shield Indemnification and it is at the clients’ discretion to assign any bills to Shield Indemnification. Should a claim reach an escalated provider dispute, or legal action has been taken by the provider; WellRithms may recommend that the claim be assigned to Shield Indemnification. All Parties will sign an agreement for the specific medical bill(s) so that all responsibility and legal liability are assigned to WellRithms. The parties include the plan/payor and the patient (when applicable). WellRithms is now solely responsible for the resolution of the balance allegedly owed to the provider, any legal fees accrued from the defense of the WellRithms reimbursement amount, and any adverse judgements/settlements paid to the provider.
What happens if the provider does not recognize the WellRithms Shield Indemnification claim transfer?
Debt transfer is a very common practice in business. However, this is not common on medical bills. Should a provider have difficulty understanding the transfer, WellRithms will continue to redirect the provider and escalate the discussion to the responsible legal representative, if necessary.
What happens if the provider balance bills the plan or patient?
The plan or patient will forward all provider correspondences to WellRithms so that we can redirect the provider to WellRithms, who is the responsible entity for any amount that the provider believes they are owed.
What happens if the provider sends the patient to collections?
It is important that WellRithms is notified in a timely manner so that we can provide a formal dispute. WellRithms will not dispute the validity of the debt, which would be considered frivolous by the debt collector. Instead, WellRithms will dispute who is the responsible party of the debt: WellRithms is responsible, not the patient since the debt has been transferred under WellRithms Shield Indemnification. The patient’s credit score cannot not be adversely affected because they do own the debt. Once the responsible party is properly established, the patient is out of the picture and WellRithms maintains sole discretion of its resolution with the debt collector and/or provider.