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Many surgeries require more than one surgeon. A qualified surgeon assisting during surgery provides an instant second opinion consultation. The assistant surgeon can perform ancillary parts of the operation while the primary surgeon focuses on completing the more complex technical tasks. The usual and customary fee for an assistant surgeon on most plans is between 13% and 20% of the fee of the primary surgeon.
Sometimes, things do not go according to plan. We discovered a claim involving a colectomy operation where both a primary surgeon and an assistant surgeon performed the procedure. See the following summary for the two providers’ claims:
Something doesn’t add up
The surgery occurred in December, and the primary surgeon’s claim was paid in March of the following year. The assistant surgeon’s claim was not processed and paid until August, which was more than eight months after the date of service. Both of the surgeons were out-of-network and had submitted the same amount of billed charges on their claims. The primary surgeon was reimbursed a reasonable fee for their services. However, instead of reimbursing the assistant surgeon a small percentage of the primary surgeon’s fee, the TPA processed the assistant surgeon’s claim for more than 19 times the amount paid to the primary surgeon!
| Surgeon | Billed Charges | Paid Charges |
| Primary | $59,130 | $2,986 |
| Assistant | $59,130 | $57,907 |
Because our client had engaged us to conduct a medical claims audit, we identified the enormous discrepancy between these two payments on the claim and submitted it for review by the TPA. The TPA readily agreed that the claim amount for the assistant surgeon was processed incorrectly and that the assistant surgeon should have been reimbursed at 20% of the primary surgeon’s payment.
This audit finding resulted in an absurd overpayment of more than $57,310 that was returned to our client’s medical plan. Had the audit not been performed, this egregious error and its related overpayment would have gone unnoticed.
Healthcare Horizons is a leading expert in providing healthcare claims audit services, identifying overpaid or erroneous claims through its 100% Difference model, and 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 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.