Lip Stitches and a Bleeding Bill
INJURY: Cut lip (diagnosis code: S01.511A ”laceration without foreign
body of lip, initial encounter”)
TREATMENT: Suture of lip (aka lip stitches)
COST: Facility charge $1900; Physician $25,000
WAIT, WHAT??
Are we missing something here? For comparison purposes, the national Medicare rate for this procedure code is around $340 and there may be occasions when the charge is approximately $700 to $1,000 when a network physician provides the service in the emergency room.
In this instance, the attending physician was out-of-network. But still, why was the non-participating provider reimbursed the full $25,000? The answer is that the third-party administrator followed the plan design, which stated that since the care occurred in the emergency room the payment should be made at billed charges.
HOW SHOULD IT HAVE BEEN BILLED?
In reality, the third-party administrator should have at least questioned the billed charges as unreasonable, if not abusive. The TPAs should have reasonableness checks in place for the out-of-network charges especially considering the new No-Surprise Billing Act holds the employer financially responsible for the payment of the charges allowed by the TPA. (Read more about the dangers of not paying attention to the requirements of this act.)
LIP CARE IS BETTER THAN LIP SERVICE
This individual’s lip probably would not have healed properly without some medical attention like lip stitches. Obviously, the hospital and the physician are due compensation for providing a healthcare service. However, the amount of the billed charges by the physician, in this case, is absurd and cannot be justified merely because this physician did not have a contract with the hospital. It turns out that fixing a busted lip really can cost an arm and a leg!
RECOVERING THE LOST BENJAMINS
Fortunately, through a comprehensive review of medical claims, we found this error right away. Your company’s health plan may have these types of claims processing errors too. An audit will help to uncover these overpayments, recover the dollars paid in error, save your employees out-of-pocket costs, and identify possible options to prevent these types of errors from occurring again in the future.
Healthcare Horizons is a leading expert in providing healthcare claims audit services, identifying overpaid or erroneous claims through its 100% Difference model, recovering millions of dollars for clients’ bottom lines with uncompromising ethics and accuracy. Since 1999, the Knoxville, Tennessee-based company has provided superior healthcare claims audits for some of the world’s largest self-insured employers, involving all national payers. We have successfully identified and facilitated the recovery of millions of dollars of overpaid claims for employers.