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Outlier Claim Review

21% Savings

In claims with outlier payments, billed charges affect the value of the outlier payment due to the facility. Therefore, it is important to ensure the accuracy of the charges as they directly impact the amount of the outlier payment beyond the base rate. For this claim, the procedure was a defibrillator insertion for a heart attack patient. The charges were originally $112,900, creating an outlier payment of $27,400.

Original Payment $27,400
Savings ($5,700)
Valid Payment $21,700

Upon review of the claim, CERiS identified and disallowed non-separately billable charges including certain nursing services and routine supplies, totaling more than $18,500. As a result, only the valid charges were re-applied to the outlier repricing and reduced the outlier payment from $27,400 to $21,700, equaling a 21% reduction in outlier payment.