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Fighting Back Against Improper Medical Billing. How WellRithms' Implant Review Process Saved Patient




Medical claims for surgeries with implant charges require physician review for proper billing to prevent overpayment. Case in point, WellRithms reviewed a $33,212 claim for an open treatment of a clavicle fracture, a procedure that requires multiple implants.


Submitting each implant as a separate line item or combining the same implant for multiple quantities into one line item, is the proper way to submit a claim for implants. On this claim, the number and type of implants used were masked under one charge totaling $16,836.55. Combining implant charges into a quantity of one "makes it difficult to reprice if you can't decipher what was used", says Jesse Nguyen M.D., Associate Medical Director of WellRithms. WellRithms always flags implants for review to ensure the correct number of implants are being billed and correctly based on implant type. Upon review of the operative notes, a Stryker ten-hole superior plate and a total of 9 screws were used- five locking screws in the plate, three non-locking screws, and one lag screw, which brings the fractured clavicle together.


“By correlating actual medical treatment with the implants used and separating the implants out by type and manufacturer, WellRithms reduced the implant charges by 78%”, says Dr. Nguyen,” a significant reduction that helped drive down the overall reimbursement to $13,312.46, a savings impact of 60%”.

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