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Medical Bill Review

Medical Cost Containment

Medical Bill Review

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Medical Bill Review The competitive landscape for medical bill review is vast and large. There are no barriers of entry in the medical bill review market place. Hundreds of companies offer experienced medical bill analysts and nurse reviewers to find un-bundling of services, and non-compensable charges. These companies can use national provider networks, Usual and Customary reductions (UCR) arguments,, and state of the art technology to deliver maximum savings. SFUR stands out in this area because SFUR not only offers what the competition offers, SFUR goes one step beyond by deploying experienced practicing physicians (often with medical coding certifications) to identify cost saving.

From 2011 through 2019, SFUR has generated $1.26 billion in savings to its payer customers.  Most of the the time, SFUR is paid on a contingency basis which typically generates a return on investment in excess of 1,500% to our payer customers.

Summary

SFUR utilizes physicians including some physicians that are certified in coding to deliver bill review and cost containment services. Except for # 1 noted below which is exclusive to Worker Compensation, these are the top denial reason utilized for both the Workers Compensation and Self Insured Health Plan market place.

1. Charge adjusted – service unrelated to the compensable injury
2. Charge adjusted – incorrect coding
3. Charge adjusted – submitted code is for a procedure which is a component of another procedure
4. Charge adjusted – medical necessity of service is unsupported by the clinical documentation
5. Charge adjusted – charge is inconsistent with State Statute
6. Charge adjusted – charge amount exceeds Usual and Customary charge for this service
7. Charge adjusted – multiple procedures performed during the same encounter

Example

In this case noted below, there are over 77 medical references listed that support the medical argument put forth. This specific case along with thousands similar to it, typically are not appealed or petitioned.

Real World Bill Review Example

Patient 1 (DOB X-XX-1962) was treated at XXXXXX Regional Hospital from 5-16-2016 to 5-17-2016. This case was selected for further review:

ICD-10-CM and CPT codes submitted indicate that the patient was seen in the emergency department and admitted for observation and diagnostic testing. Principal diagnoses submitted on the claim include:

  • M54.5 – Low back pain
  • F17.210 – Nicotine dependence, cigarettes, uncomplicated

Brief Summary: The patient presented to the ED with acute lower back pain following a strain-type injury while “lifting and twisting” There was no fall or other trauma documented. 11:29 Arrival in ED by private vehicle / wheelchair (not by ambulance/backboard). Physical exam documents normal vital signs, no fever, normal motor, sensory and reflexes. Gait was limited by pain. The patient underwent two advanced diagnostic imaging studies, laboratory studies and was admitted to observation status. He was discharged home the following day on oral medication.

The clinical and billing information submitted was reviewed and several concerns were identified:

1. Diagnostic imaging for acute low back pain:

CT Lumbar Spine w/o contrast 72131TC $6354.54 MRI Lumbar Spine w/o contrast 72148TC $6862.04

Analysis: The patient presented with uncomplicated (no neurologic complaints or objective deficits) low back pain related to lifting. A CT lumbar spine was ordered prior to the patient even receiving the first dose of pain medication. The patient was admitted to observation status and subsequently also had an MRI lumbar spine (w/o contrast). Both studies showed no clinically significant findings.

Multiple clinical practice guidelines consider diagnostic imaging to be medically unnecessary for patients such as this with acute low back pain due to a simple strain injury. Exceptions to this rule include patients with acute neurologic deficits, a presenting history of significant trauma (deceleration, fall, penetrating trauma) or patients with underlying medical conditions (fever, cancer). This patient did not present with any of these exceptions.

Therefore it is recommended that the charges for these tests be disallowed as not medically necessary.

2. Laboratory testing for acute low back pain:

  • Revenue Codes 300,301,305 multiple CPT codes totaling $1088.28

Analysis: The patient presented with uncomplicated (no neurologic complaints or objective deficits) low back pain related to lifting. Multiple clinical laboratory tests including thyroid testing, chemistry, hematology, liver function tests, magnesium and phosphorus were ordered. The lab work showed no clinically significant abnormality. Despite this finding, and without any documentation of clinical necessity many of the same tests were reordered for the following morning, less than 24hrs following the first set.

Multiple clinical practice guidelines consider clinical laboratory testing to be medically unnecessary for patients such as this with acute low back pain due to a simple strain injury. Repeating (within 24hours) many of the same tests, despite normal results on the first set similarly cannot be considered medically necessary without clinical documentation to support this testing.

Therefore it is recommended that the charges for these tests be disallowed as not medically necessary.

3. Outpatient observation services for acute low back pain:

  • Hospital Observation Services G0378 26 hours $4200.36

Analysis: The patient was admitted to hospital observation status (for “intractable” back pain) after receiving a total of 2mg of hydromorphone via the subcutaneous route and a muscle relaxant via the intramuscular route. The admission was ordered at 14:01, about 2.5 hours after his arrival in the ED. There was no attempt to make further efforts to bring the patient’s pain under control before deciding to admit him. The patient was not vomiting, so there was no indication to admit him for parenteral (rather than oral) medication. Therefore it is recommended that the charges for these tests be disallowed as not medically necessary.

SUMMARY:

Billed charges

$26,237.83 Disallowed charges $6,354.54  $6,862.04,   $1,088.28,   $4,200.36  $18,505.22

Net Charges   $7,732.61