A Case of Excessive Billing

Incentive Spirometer Administration

Claim Summary

Provider appealed our medical bill review reduction recommendations and balanced billed the member. Health Cost Control (HCC) reached out to the member and started patient advocacy. The follow-up call to the business office was escalated to the billing supervisor. An HCC representative requested a copy of the implant invoices for consideration of additional reimbursement along with other supporting documents. This request was declined and provider forwarded this case to their legal team.

The provider’s legal team refused to supply any documentation to support their charges and demanded 90% of billed charges. HCC, with our client’s approval, countered with an additional payment equaling 49% of billed charges. The settlement was declined.

Further Findings

HCC identified 28 charges totaling $5,426.12 for an Incentive Spirometer. The device costs under $4.00. The individual treatment charges of $193.79 were for the administering/teaching in use of this device. We spoke with the member and he stated they were only present one time when giving instruction on how to utilize the spirometer. The member’s wife, who is a Registered Nurse, and constantly present with her husband, confirmed that no one afterwards asked or logged in how he was doing with the spirometer. A very high mark-up on a $4.00 investment.

Information was shared with provider and legal team. HCC questioned if this is normal billing practices for this service with other payors.

Procedure

  • Fusion of 4-8 vertebrae
  • Other cervical fusion of the anterior column, anterior technique
  • Excision of bone for graft, other bones

Claim Specs

  • Out of Network for Self-Funded Employee Retirement Income Security Act (ERISA) Plan
  • Total billed charges $183,691.81

  • Charges above usual, customary, reasonable $145,280.06

  • Inappropriate charges $1,287.90

  • Incomplete documentation charges $8.40

  • Recommended allowable $37,115.45

adminkenA Case of Excessive Billing