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• Billed Charges: $632,648

• WellRithms Reductions: $456,106

• Final Payment: $1,064 (o.02% of billed charges)

Significant Findings

WellRithms reduced charges of a newborn case by 72% for an In-Network Hospital Itemized Bill Review, with help from BRAID

Background

A full-term baby delivered by C-section had pulmonary valve atresia, pulmonary artery atresia and a malformed tricuspid valve, leading to acute respiratory failure. Treatment involved placing a stent in the pulmonary artery, which was covered under a Michigan electrical union’s group benefits plan. The baby spent 26 days in the neonatal intensive care unit before being moved to general nursery care for 22 days. Upon review of the itemized charges WellRithms uncovered several inflated or erroneous charges.

Results

Using its Sustainable Claims Pricing (SCP) to reprice a $632,648 claim, and incorporating WellRithms’ Optical Physician Utilization Synthesizer (OPUS) 3 product, WellRithms determined that a fair payment was $176,542.

What sets OPUS 3 apart from OPUS 1 and OPUS 2 is that it immediately flags inflated or erroneous charges in an itemized bill and analyzes the itemized bill line-by-line to reprice drugs, supplies, and implants. WellRithms then determines the allowable charges based on the facility’s reported cost-to-charge ratio.

As part of this claim review, which was driven by machine-based learning, WellRithms found that:

• The hospital billed for about $33,700 worth of supplies, none of which are separately reimbursed. Those items included anything from bandages and guidewires to sheets to cover the patient.
• Of roughly $6,000 in implants that were billed, nearly all of them were guidewires that are considered by commercial insurance standards to be inclusive to the catheterization procedure, and are not paid separately. Unlike the stent, which cost $830, they were not left inside the body and should never be considered implants. This discovery dropped that portion of the bill for implants to $5,200.

Through meticulous examination with the assistance of machine-based learning, WellRithms not only provided the plan with significant financial benefit, but also highlighted its devotion to equitable and transparent healthcare billing practices. An ability to quickly apply a cost-based approach to repricing medical claims, which are among the biggest expense for most employers, is proving to be a game changer in the bill-review space.