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• Billed Charges: $54,765

• WellRithms Reductions: $42,361

• Final Payment: $12,404 (22.6% of billed charges)

Significant Findings

How WellRithms’ review uncovered excessive charges for two related medical bills in a workers’ compensation case.

Background

This Missouri workers’ compensation case involved two separate patient bills. Missouri is one of six states without a statewide fee schedule for workers’ compensation care, so providers are paid on a “usual, customary, and reasonable” (UCR) basis. The first bill, from a 2021 urgent care visit, included a visit and a knee x-ray, totaling $1,036. The second, a 2022 outpatient hospital bill for knee surgery, featured charges for surgery, implants, respiratory services, drugs, and injections, totaling $53,699.

Results

The urgent care bill was straightforward yet overpriced for a standard office visit and x-ray. The excessive charge of $1,036 for a basic knee consultation and x-ray was reduced to $335, aligning more accurately with the services rendered. The outpatient hospital bill included charges for procedures and items not used or billable to the facility, such as nerve block charges typically billed to the anesthesiologist and charges for four implants when only two were used. Through its Classification, Edits, and Audit (CEA) and Sustainable Bill Pricing (SBP) Systems, WellRithms conducted a detailed review of both bills, identifying and rectifying these errors:

• Excessive Drug Markups: WellRithms identified significant overcharges on medications, notably fentanyl, which was marked up 53 times its actual cost— billed at $106 while costing only $2.
• Billing for Standard Supplies: The surgery bill included $5,617 in charges for surgical supplies that are typically part of the overall procedural cost, not individually billable. WellRithms reduced these charges to $0.
• Inflated Implant Costs: The initial charges of $2,626 included four implants when only two were used during the surgery. WellRithms’ reduced this to $612.

Ira Weintraub, M.D., Chief Medical Officer at WellRithms, emphasized the company’s commitment to fair pricing, noting, “In the realm of healthcare billing, it’s essential to distinguish between legitimate costs and those inflated beyond reason. When we come across a medication marked up to 53 times its cost, we challenge these charges. Our goal is to ensure that workers’ compensation bills reflect genuine charges plus a fair profit, not opportunistic overpricing.”

These adjustments and others not only corrected overbilling but also brought to light common billing errors and misconceptions in medical practices. The WellRithms CEA and SBP systems played a crucial role in this process, highlighting the necessity for vigilant review to prevent unjustified costs.