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• Billed Charges: $49,000

• WellRithms Reductions: $47,500

• Final Payment: $1,500 (3.1% of billed charges)

Significant Findings

For an out-of-network bill review and repricing, WellRithms reduced a podiatrist’s $49,000 bill to $1,500.

Background

This case for a group health member involved a podiatrist in New York performing surgery for Morton’s Neuroma, a common foot ailment. Traditionally a straightforward procedure, the bill appeared vastly inflated at $49,000. The claim utilized multiple procedure codes, none corresponding to the standard for Morton’s Neuroma. These codes implied complex neuroplastic surgery, unjustifiably inflating the cost and complexity of the actual procedure performed.

Results

WellRithms, leveraging its Classification, Edits, and Review (CER) system, scrutinized each line item, identifying critical discrepancies. By reclassifying all charges into the appropriate single code, WellRithms corrected the unbundling strategy employed, aligning the bill with the true service provided.

However, the embedded physician review, drawing on the experience of seasoned surgeons, was pivotal in discerning the true nature of the procedure versus the billed services. As Ira Weintraub, M.D., Chief Medical Officer, noted, “In cases like this, the real difference lies in understanding the surgery itself, down to recognizing anatomy that was not classified and coded correctly. Our team’s surgical experience is crucial in differentiating between genuine complexity and coded complexity.” The physician team identified key errors:

• Basic Procedure Code Missing: Identification of a discrepancy where the provider used five separate codes, none of which correspond to the standard 28080 code for Morton’s Neuroma surgery. These codes suggest complex neuroplastic surgeries that do not apply to the actual procedure done.
• Billing for Duplicate Services: The billed procedures, such as the cryogenic removal of the nerve and ligament dissection, are standard parts of the Morton’s Neuroma surgery and should not be billed separately.
• Misclassification of Anatomy: The billed nerve procedures were misclassified, using codes meant for major peripheral nerves with specific names, such as the sciatic or radial nerve. However, Morton’s neuroma involves interdigital nerves, which are not major peripheral nerves and therefore do not warrant the use of such codes.

This meticulous process culminated in a significant reduction, reducing the $49,000 to the standard $1,500 for Morton’s Neuroma surgery. WellRithms’ combination of technological precision and medical expertise proved instrumental in transforming an unjustified bill into a fair charge, embodying WellRithms’ commitment to billing integrity and fairness.