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Medical Cost Containment Group

Medical Cost Containment

Medical Cost Containment Management

URAC Accredited Independent Review Organization

Medical Cost Containment SFUR defines medical cost containment as the process of leveraging medical and business knowledge to potentially lower the cost of medical bills. Our results speak for themselves. Typically, if our payer customers pay a fixed fee for our services (regardless of the savings outcome), they will generate a 400% return on investment because of the savings we generate. If our payer customers opt for percent of savings model, where SFUR only gets paid if savings are generated, the return on investment is over 1,500% to our payer customers.

Summary

The broad category of medical cost containment includes bill review, clinical chart review, negotiations which result in signed settlements, denials of selected lines in claims, and/or the changing of the primary diagnosis and/or DRG assignment in a DRG claim. All of these investments can results in reduction of claims submit to health plans and worker compensation payers.

Between 2012 and 2019, SFUR has achieved savings in 78% of the bills it has received from its payer customers.

SFUR Fees are percent of savings based. If savings are not generated, there is no fee charged.

Example

Below is an real world example where a hospital vacillated between inpatient and outpatient because of the implications of the reimbursement.  SFUR recommended disallowing two service charges and denying the entire bill until physician orders are furnished to determine if inpatient versus outpatient status.

The operative procedure is coded incorrectly.

Three separate codes are reported:

  • 27599 – Unlisted procedure, femur or knee
  • 27380 – Suture of infrapatellar tendon; primary
  • 27524 – Open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft tissue repair

Review of the operative note documentation supports the use of 27524.   The patient underwent ORIF of the patellar fracture.   A part of this was closure of the patellar retinaculum, included in the definition of 27524 (“soft tissue repair”).  The operative note does not describe a separate (distant)  injury to the infrapatellar tendon and therefore this code (and modifier -XS)  is unsupported by the documentation.  Similarly, there is no documentation whatsoever to support the reporting of the unlisted procedure code (27599).

The encounter was billed as an outpatient procedure (Bill Type 131) but it was noted that the patient was in the hospital for 2 days.   Excess observation charges have already been disallowed.    There is some documentation that suggests that perhaps the patient was admitted as an inpatient but later a decision was made to treat it was an outpatient visit (possibly to increase reimbursement):

As an inpatient, the allowance would be determined by the per-diem method (rather than 75% of non-implant charges) , as the total charges (esp after the reductions  above) are below the outlier threshold. Reimbursement for implants would be determined according to invoice cost, rather than as a percentage of charge.   Thus, reclassification as an inpatient would likely significantly lower the allowance.  Inpatient status is determined by physician order (confirmed by the FL Division of WC).   However, the physician orders for this case were not provided by the facility:

Recommendation:

Disallow the following:

  • 27599 – Unlisted procedure, femur or knee                        (documentation does not support the code charged)
  • 27380 – Suture of infrapatellar tendon; primary                (documentation does not support the code charged)

Consider disallowing the entire claim pending review of the physician orders and verification of outpatient vs inpatient status in order to determine the proper methodology for reimbursement.