Direct Correlation Between Claim Complexity and Billing Errors
Heart transplant cases are very complicated and involve multiple complex hospital bills with hospital stays ranging from one to two weeks. It is standard practice for specific charges to be included as part of the primary anchor claim (ex: heart-lung bypass charges, guide wires, etc.) Within the global case, expected bills would include the inpatient transplant recipient claim, multiple physician bills, outpatient post-op bills for lab charges and monitoring of the implant for rejection. CERIS takes a holistic approach to these reviews by pulling all medical bills together. CERIS will review, correct, and re-allocate payments for the entire case.
In this particular case, CERIS reviewed a heart transplant claim for a large national payer. The patient was a 56 year-old male with hypertensive heart and chronic kidney disease with heart failure. This individual underwent a heart transplant, which is considered less complicated than most heart bypass surgeries, including a coronary artery bypass graft. A subsequent procedure was performed to insert a pacemaker.
Upon review, CERIS found two physician bills included in the global case that were unrelated to the transplant procedure as well as routine services, routine supplies and medical equipment not separately reimbursable. These errors results in an inflated reimbursement. Despite the procedure’s straightforward nature, CERIS’ transplant review resulted in savings to the payer of $17,000.
Transplant claims are sensitive yet in CERIS’ experience are still subject to inflated billing and errors like any other inpatient bill. We as a community have a fiduciary responsibility to review any claim.
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