Scenario:
While working, the employee sustained an injury when they were accidentally stuck with a used syringe. Per protocol, the employee was sent for urgent care where a battery of tests were performed. During the course of these tests, it was discovered the claimant was also suffering from hypertension. The claimant was admitted and kept under observation for three days before being released. The billed charges totaled $15,749.13.
Solution:
Alpha Review received the bills and related documentation and submitted it to our Specialty Review department. Our Certified Professional Coders (CPC) conducted an initial review checking for proper coding for the admitting diagnosis. This initial review reduced the charges by $9,350.51.
The bill was then submitted to our nurses who reviewed for appropriate treatment for the compensable injury. During the course of the nursing review, it was discovered that the three-day observation admission was for a non-compensable, pre-existing diagnosis of hypertension. They also identified additional medications and treatments that were billed but were not compensable based on the diagnosis. In total, they saved an additional $5,573.53 above what our initial CPC review was able to save.
Final Outcome:
Billed Charges = $15,749.13
Specialty Review Savings = $14,924.04
Total Allowance = $825.09
A total reduction of 94.76%!
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