Case Study: Charges Exceeding Daily Limits

Alaffia Health’s payment-integrity-as-a-service platform provides a turnkey solution for the healthcare billing fraud, waste, and abuse costs that make up 6–25% of their healthcare expenditures each year.  Plenty of companies make big promises, but Alaffia delivers big results to the bottom line. Let’s look at a case study where Alaffia rose to the challenge. 

The Situation: Healthcare Billing Charges Exceeding Daily Limits

Utilizing our proprietary automated systems and the expertise of our healthcare billing and coding experts, we reviewed a claim for services conducted from June 14th through July 8, 2018. The uniform bill noted that the provider billed revenue code 410, respiratory services, for 26 units and a total of $20,013.55 and this raised a flag. Our team obtained the applicable records and completed a line-by-line review of the itemized bill for the claim.

Under current medical billing and coding rules, the max units allowed for vent management (94003) is one per day. By reviewing each charge, we identified that the facility overbilled for vent management on the following days:

  • July 1st: 7 times at $782.13 per charge, resulting in $4692.78 in overbilled charges.
  • July 2nd: 4 times at $537.50 per charge, resulting in $1612.50 in overbilled charges. 
  • July 3rd: 3 times at $537.50, resulting in $1075 in overbilled charges. 
  • July 4th: 3 times at $537.50, resulting in $1075 in overbilled charges.
  • July 6th: 3 times at $537.50, resulting in $1075 in overbilled charges. 
  • July 7th: 3 times at $537.50, resulting in $1075 in overbilled charges. 

Our Results:

The initial claim included $20,013.55 in charges for revenue code 410. 

Alaffia identified overpayments for this claim and rev code of: $10,605.28.

We were able to reduce the amount of this claim to: $9,408.27.

With an estimated $300 billion in healthcare billing fraud, waste, and abuse charges every year in the healthcare sector, claims like this example are more common than you think. Alaffia works directly with you to prevent and recover overpayments like this. Best of all,  our contingency-based fee structure means we only get paid for results.

Book a consultation with Alaffia and learn how we can get results for you.

Highlights: 

  • Contingency-based fee means no up-front cost. We get paid when we save you money.
  • AI + machine learning technology allows us to review more line charges
  • $150 per plan member per year in potential annual savings.
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