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• Billed Charges: $172,982

• WellRithms Reductions: $94,552

• Final Payment: $78,430 (45.3% of billed charges)

Significant Findings

How WellRithms’ Classification, Edits, and Review (CER) System Identified Overbilling in a $172,982 Laparoscopic Surgery Assistant Surgeon billed $172,982, reduced to $94,552, representing a savings of $78,430.

Background

A 52-year-old group plan member in California underwent multiple laparoscopic procedures, and the WellRithms Classification, Edits, and Review (CER) System found incorrect charges on an assistant surgeon bill, resulting in a 45% reduction in charges as a precursor to repricing, which added even more to the savings.

Results

In this case, WellRithms faced the challenge of analyzing a complex surgical bill involving multiple laparoscopic procedures. The initial issue centered on the separate billing of a paraoesophageal hernia repair, which was performed alongside a laparoscopic sleeve gastrectomy. Utilizing their CER system, WellRithms identified this billing discrepancy and escalated it for a detailed physician review.

During this review phase, led by specialists including Jesse Nguyen, MD, the team meticulously evaluated the procedural specifics. Dr. Nguyen noted, “Our review process revealed that the hernia repair, typically included in a sleeve gastrectomy, was separately billed. Our focus in such cases is to ensure that each item on the bill accurately reflects the care provided. Correcting this billing error was a key part of our analysis.”

In this case, WellRithms’ intervention led to revisions in the billing, ensuring accuracy and fairness:

• Exclusion of Redundant Charges: The hernia repair charge was excluded, as it was integral to the primary laparoscopic sleeve gastrectomy.
• Validation of Appropriate Charges: The liver biopsy charge, a minor yet distinct procedure performed during the surgery, was confirmed to be correctly billed.
• Substantial Cost Reduction: As a result of these adjustments, the original bill of $172,982 was reduced to $94,552, reflecting a more just and accurate billing outcome.

Throughout this case, the CER was integral in ensuring that all information on the bill was accurate, including the type of bill and provider details. This initial step set the stage for a more detailed review, where the medical team’s expertise came into play.

With these adjustments made, the next step was the application of WellRithms’ Sustainable Claims Pricing (SCP), providing further savings and incorporating price recommendations based on a thorough review of standard payments, geographical and state-specific financial considerations, and inflationary adjustments. These SCR savings are further detailed in a companion case study.