Qmedtrix

Qmedtrix reviews, corrects, and validates medical bills for inappropriate and incorrect billing, and identifies fraud and abuse. Founded in 1996, Qmedtrix offers a nationwide out-of-network solution, supported by proprietary decision software and a database of paid and charged data.

Situation

50% of all medical claims have billing errors. All medical claims should be reviewed and corrected prior to being submitted to a network (like a PPO) or being paid by an individual or a company. By first reviewing medical claims, identifying and correcting inaccuracies, costs go down significantly. Employers and individuals save money while reimbursing fairly and reasonably for services received.

Solution

The past two years we have identified one-half billion dollars in errors and abuses, and corrected them for large national payers of health care. From large payers to individual consumers, both submit their claims to us for review where we apply our decision software and methodology for analysis and recommendation. Our methodology determines appropriate levels of medical service for procedures, identifies common abuses such as unbundling, inappropriate use of modifiers, and non-use of global coding rules. It also recognizes geographic inflation and cost differences prior to making a fair and reasonable recommendation for payment/reimbursement.

With this recommendation, along with its clear descriptions outlining what was discovered in the analysis and why the recommendation was made, individuals and companies are better informed as to what the real price for health care is; and they are provided a clear summary of corrective measures taken to correct the inaccuracies and abuses.

Better Health & Lower Costs

Out-of-network medical charges are subject to significant abuse, charge inflation, unbundling, and upcoding. The following case studies represent recent payer experiences:

Arizona Hospital Bill: An Arizona woman injured her back and had surgery for a displaced lumbar disc. Fusion was not performed and no implantable hardware was used. She was in the hospital for six days. Qmedtrix reviewed the bill based on reasonable, usual and customary rates for this service. The charges were $23,747.72 in excess of reasonable, usual and customary. The most significant overage was for the room and equipment used for the surgery. The hospital charged $16,316.40 for the use of the room/equipment, as opposed to the $3,865.76 that more closely resembled its costs, plus a reasonable profit. The total original charges were $35,811.95; our re- commended reimbursement for the final payment was $12,064.23. The original bill was nearly three times higher than the final payment.

New Jersey Hospital Bill: A New Jersey man spent three days in a hospital for a lower back fusion with implants and was billed $86,536. Charges for the implants and room rate were both inflated compared to other facilities in the area. Review of the charges showed $16,810 as the fair and reasonable amount. After negotiation, the provider signed an agreement for $20,000. The original billed amount was 332 percent higher than the settlement amount.

Oregon Hospital Bill: A man in Oregon developed pneumonia, which led to respiratory failure. He spent 20 days in an Oregon hospital and was billed $130,422.61. Using a comprehensive database of paid and billed data for services nationwide, inappropriate charges were identified in a variety of areas. The most significant differences were $34,872 for intensive care services, compared to the $24,616 established as fair and reasonable. Pharmacy charges of $30,365.98 were audited and reimbursement recommended at $17,267. The line item for CT scan was $5,617, compared to the usual and customary charge of $2,288. Finally, respiratory services were billed at $13,822.71, compared to the $6,686 recommended reimbursement. The total recommended reimbursement was $81,443.

The hospital made a case for its higher charges based on the length of stay and the patient’s complications, and a final settlement of $100,000 was agreed upon. This represents savings of more than $30,000 for the patient, while providing an acceptable profit margin for the hospital. The original bill was 30.4 percent higher than the final settlement.

Oregon Air Ambulance Bill: An Oregon woman with a drug overdose went to a nearby hospital. Because it did not have an intensive care unit, she was referred to another hospital. Unfortunately, she was not moved for three hours after this determination and her situation steadily worsened until it was necessary to air lift her to an alternative facility. The air ambulance bill sent to her insurance provider by the first hospital was $6,120. Although the hospital, which did not serve her needs, paid a discounted rate to the air ambulance provider, it charged the patient at a much higher rate.

After a thorough review of the itemized bill, it was ascertained that the reasonable, usual and customary charge was $4,079.32.

Because it was questionable whether an air ambulance was necessary, or only required because of the lengthy waiting period for care, the payer was not eager to reimburse the hospital for an amount greater than that considered fair and reasonable. The negotiators approached the hospital with the recommendation, based on usual and customary charges for this service, and were told that nothing less than the originally billed amount would be acceptable.

The provider appealed the original review and a second review was conducted on the billed charges. Additional information was collected and documentation confirmed that the charges were considerably in excess of usual and customary. The recommended reimbursement of $4,079.32 was offered again, and the amount was not disputed a second time. The original bill was 50 percent higher than the final accepted reimbursement.

Georgia Ambulatory Surgery Center Bill: A man in Georgia injured his shoulder, probably through a repetitive motion necessitated by his job, and went for treatment. At the ambulatory surgery center, the surgeon began with an arthroscopy, a process that uses a scope to diagnose and make minor repairs. When it became clear that the surgeon could not complete the necessary repairs through the arthroscopic process, an incision was made and a complete shoulder rotator cuff repair was performed.

Because this was one surgical experience, the allowance for the rotator cuff repair included the costs of the arthroscopy, as well as any equipment, supplies, tools, anesthesia, etc., required during the surgery. When the bill arrived, however, the arthroscopy, supplies, anesthesia and pharmaceutical supplies were listed as separate services and billed additionally—over and above the allowance for the shoulder reconstruction.

This unbundling—a commonly used method for increasing charges—has the effect of double dipping. After the bill was reviewed, allowance was made for full payment for the rotator cuff reconstructive surgery. All of the unbundled charges that were already accounted for within the allowance for the rotator cuff reconstruction were disallowed. Reductions in charge for the implants used in the procedure to the reasonable, usual and customary amount were also recommended.

The result was that the $9,385.05 bill was reduced by $6,712.85 to $2,672.20 for this outpatient surgery. The original bill was 3.5-times higher than the accepted payment.

Footnotes

• Moody, Robin L. “Fighting Health Fraud.” The Business Journal. 8 February 2004. http://www.bizjournals.com/portland/stories/2004/02/09/focus1.html
• “Intracorp's New Suite of Managed Care Tools Helps California Employers Achieve Workers' Compensation Savings; Strategies Target Specific Cost Drivers in the State.” Intracorp website. April 2004. http://www.intracorp.com/IntracorpHome/media/press/041904.jsp
• Moody, Robin L. “Company Puts a Container Around Bogus Business Practices.” The Business Journal. 13 June 2003. http://www.qmedtrix.com/news/articles/Qmedtrix_BJ_Top100.pdf
• Smith, Donald A. “Looking Back – 2003 in Review.” AZ@Work. May 2004 http://www.scfaz.com/publish/article_487.shtml