April 6, 2017

Recent Successes

 

In this 2016 complex, emergency spinal case, the total billed charges were $197,459, and the initial reimbursement was  $3,282.  The providers’ internal billing department filed one appeal and did not receive a response.  We filed a second level appeal, and  received additional payments totally $154,678.


This was a 2015 case where the patient had a double mastectomy.  The complex surgery involved two out-of-network breast reconstructive co-surgeons and an assistant surgeon.  Billed charges exceeded $150,000.  The initial payment from the insurance company was $213 collectively for the co-surgeons and for the physician assistant.  Our team analyzed the case and utilized our vast knowledge in this medical billing area resulting in an additional payment of over $100,000 in early 2017.


In this 2016 case, the patient had no out-of-network benefits through a self-insured policy. The provider performed a bilateral mastectomy and was reimbursed. After our client continued care with follow up surgeries, the insurance company refused to reimburse them for these additional services. A First Level Member Appeal was filed on their behalf, and we were able to recover close to 100% of the billed charges in January of 2017.


In early 2016, a resection of recurrent right breast cancer was performed on a patient, which also required an intraoperative consultation for plastic reconstructive closure. After filing an appeal stating that the rate of reimbursement was too low and challenging the payor on various Federal and State law theories, the provider was reimbursed $28,124 of the $31,824 in billed charges.