Partners was notified by TPA of a 65- year old patient in the hospital, diagnosed with congestive heart failure. The patient’s prognosis was poor, with treatment including Ventricular Assist Devices (LVAD and RVAD) and ECMO. Billed charges were in excess of $2,700,000. After applied PPO discount the total payable was $1,100,000.
With all parties involved having the client’s best interests in mind, Partners, with the cooperation of the TPA, referred the claims for vendor bill review. Partners assures the TPA all findings would be supported by the vendor and the PPO discount will not be jeopardized.
Bill review identified $366,992 of additional savings and resulted in a new payable amount of $777,208. Although a significant PPO discount was originally applied, with the Partners’ clinical review, we were able to identify experimental treatments and billing errors that would not have been caught otherwise.