A man fell on an outstretched arm suffering a fractured carpal scaphoid (one of his wrist bones). The fracture was not likely to heal on its own and required outpatient surgery, the preferred method of treatment for this injury to ensure proper healing. WellRithms’ bill review system, Harmony, processed this $24,887.62 claim, flagging implants for physician review.
The implants used were 2.5mm headless screws, typical screws used in this repair. In order to submit a claim for each implant, each implant model number must be recorded onto the operative log as it is used. There were a total of 11 screws listed on the uniform medical billing form (UB), and the operative log accounted for 12. “It’s anatomically impossible to put more than two screws into the scaphoid. The screws would have to be placed parallel, otherwise, they will bump into each other. A large human, like Andre the Giant, would not even need more than two screws, let alone the average adult male”, remarks Jesse Nguyen M.D., Associate Medical Director for WellRithms.
Obviously, 12 screws weren’t used and this is an example of abusive billing practices. The implant charges were $8702, WellRithms denied ten, and applied cost-plus pricing on the remaining two, recommending a $1049 payment. An 88% reduction on implants alone that helped further reduce the bill to the final recommended payment of $9762, for a total saving of 61%.
