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Bill Review Uncovers Upcoding in Finger Amputation Surgery


Background:

A butcher was injured on the job when he cut off the tip of his index finger at the joint. He was rushed to the emergency room and a plastic surgeon was consulted to discuss treatment options. It was determined that the best course of action would be to amputate the finger at the joint, rather than attempting replantation.


Case:

When the bill for the surgery was reviewed by Melody™, it was flagged for multiple procedures including amputation, nerve repair, nerve graft, and an unlisted code. Upon further review by the WellRithms Chief Medical Officer, an orthopedic surgeon with 45 years of experience, it was found that these additional procedures were not actually performed. The surgeon had simply cleaned and closed the wound, trimmed the bone, and cut the nerve back.


Proven Result:

As a result of the review, the surgeon's bill of $200,862 was reduced to $1704. This significant reduction was due to the identification of fraudulent upcoding, which is the practice of billing for more expensive procedures than were actually performed. It is important for healthcare billing to be accurate in order to keep costs fair and reasonable.



Lessons Learned:

This case highlights the importance of thorough and accurate bill review in the healthcare industry. Upcoding can drive up costs for patients and payers, and it is important for companies like WellRithms to identify and address these issues. It also demonstrates the value of having experienced physicians reviewing bills and identifying discrepancies.

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