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• Billed Charges: $52,555

• WellRithms Reductions: $31,376

• Final Payment: $21,179 (40.3% of billed charges)

Significant Findings

In reviewing and repricing a workers’ compensation claim, WellRithms slashed 60% from five inflated bills for disc replacement. Injured worker’s bills inflated to $52,555 by hospital, repriced to save $31,376.

Background

A 41-year-old man working for a ventilation and air conditioning company was fixing an AC unit when upon glancing up to his left felt immediate neck pain that radiated down his left arm. The discomfort persisted for about a week before he went to the emergency room for treatment that was billed as a workers’ compensation claim in Missouri. Missouri is one of just six “UCR” states where providers are free to charge usual, customary and reasonable rates.

What started as a June 2023 ER visit with the lowest level of acuity was followed more than a month later by a cervical spine X-ray with up to five views. The case mushroomed into several expensive visits at one of the nation’s higher-charging facilities. An initial outpatient hospital visit generated the first of five medical bills totaling $52,555, most of which involved a surgical procedure that occurred about four months after the injury.

Results

Using its Sustainable Bill Pricing (SBP) product to review and reprice workers’ compensation claims, WellRithms determined that a fair price was $21,179. SBP is an enhanced artificial intelligence system that automatically adjudicates bills within seconds to ensure everything is priced correctly. Able to reprice each line of the bill, which has separate CPT or revenue codes, it analyzed the hospital’s known itemized charges and markups, uncovering several anomalies along the way. They included:

• Disc replacement for an acute herniated disc, which is unusual unless there are persistent problems with post-disk replacement that include arthritic changes.
• Implants priced at $20,000 that should have been $6,500 based on what they cost the hospital, including a 25% markup.
• A $180 charge for drapes used in surgery to cover the microscope and operating table that cost 50 cents.
• A $35 drug that cost 62 cents.
• A burr billed at $800 that cost $90.
• A $100 charge for skin glue applied on top of stitches in the subcutaneous that cost about $5.
• A separate bill for surgical equipment was incurred that should have been included in the surgery fee.

The facility delivered questionable care at inflated prices. However, WellRithms’ SBP flagged those flaws, and in the process significantly reduced the bill for the claimant’s employer.