In our line of work, we always come across egregious billing practices – some worse than others. But few were as brazen as a podiatry procedure done in December 2022 at a New York City clinic that is notorious for over-billing its patients.
Talk about securing a foothold in the murky world of fraud, waste and abuse; this claim checked each of those boxes. The result is that we reduced the total charges of $169,410 to $631.
Here are the Details
The podiatrist’s assistant billed $169,410 for 12 different CPT codes that included a right-foot bunionectomy, removal of bunionette and hammertoe repair and two capsulotomies, which release or lengthen tightened tendons and ligaments that cause joints to contract. In addition, a pin that had previously been placed in the patient’s left foot for a different surgery also was removed.
Our medical review team started by rejecting all of the CPT codes that do not recognize an assistant surgeon as necessary to complete the procedure as per standards developed by all of the major surgical societies. These included the primary procedure code, adjacent tissue transfer billed at $45,240, removal of implant billed at $7,560, an injection billed at $2,800, correction of a hammertoe billed at $17,500, complex wound closure billed at $7,070, and X-rays billed at $1,800. WellRithms physicians denied $96,480 of the charges because an assistant is not needed for these procedures.
Not only is an assistant not needed for the soft-tissue rearrangement procedure and complex wound closure, but these charges represent fraudulent billing because they were used to close the wounds that were made by the surgeon. A surgeon cannot bill separately to close any wounds he or she created to perform the surgery.
The only portions of the procedure wherein an assistant is needed were for the bunionectomy and metatarsal osteotomy, which were egregiously charged, and WellRithms repriced these codes to a usual, customary and reasonable amount.
Cost Savings
Our price recommendation was less than 1% of billed charges. There is no surgery that garners more than $100,000, let alone foot surgery in which the paid amount to the surgeon is typically $2,500 to $3,000. The primary surgeon in this case billed only $33,430, about one-fifth as much as the assistant.
Even more absurd was the assistant billing $810 for durable medical equipment that was a post-operative boot. There is no explanation for a professional fee being attached to a piece of durable medical equipment.
Once our work was done, our client saved $168,779 on an assistant surgeon’s attempt at fancy footwork around billing.
For more information on how WellRithms can get you results, contact info@wellrithms.com.