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• Billed Charges: $23,393

• WellRithms Reductions: $$13,023

• Final Payment: $10,370 (44.3% of billed charges)

Significant Findings

In Missouri, a standard shoulder procedure was initially billed at $23,393, but a WellRithms workers’ comp bill review and repricing reduced the payment to $10,370.

Background

Missouri is a Usual, Customary, and Reasonable fee state for workers’ compensation reimbursement. A case there involved standard surgical codes for a common shoulder procedure, including extensive debridement and biceps tenodesis. Despite the routine nature of the surgery at an Ambulatory Surgery Center, the billing revealed overpriced items and inappropriate charges. Specifically, the billing included overpriced implants and two additional codes—one unlisted and not payable, and the other incorrectly billed to the surgery center instead of the anesthesiologist.

Results

The application of WellRithms Sustainable Bill Pricing to this routine bill resulted in a detailed correction and cost reduction:

• Implant Price Adjustment: The implant, initially billed at $2,528, was recalibrated to $551, aligning with its actual cost of $441 plus a standard markup.
• Elimination of Unlisted Code: The unlisted code 64999, not applicable to the procedure, was identified and removed from the bill.
• Correct Allocation of Codes: The misallocated code 64415, incorrectly billed to the surgery center, was reallocated to the anesthesiologist, reflecting the actual service provided.

Bill Reductions Included

This meticulous approach to cost reassessment demonstrates WellRithms’ ability to reduce routine procedure costs and highlights the potential for large-scale savings, as these procedures occur more commonly than expensive but rare surgeries. For the management of Workers’ Comp bills, these common billing errors often represent untapped cost reductions.

Ira Weintraub, M.D., Chief Medical Officer, noted, “Routine procedures are often overlooked in billing reviews, but they are where we frequently find significant inefficiencies. We ensure these common surgeries are billed fairly, reflecting real costs and services. What might seem like one small reduction of $13,000 can add up quickly when it’s a common billing problem for a common procedure.”

The case highlights the impact of fair bill repricing in workers’ compensation. Workers’ compensation bills often involve routine procedures similar to the shoulder surgery examined.