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Health Payer Consortium Health Payer Consortium

CASE STUDY: 56-year-old male with rotator cuff tear

A 56-year-old male was treated for an unspecified rotator cuff tear/ shoulder rupture that was specified as “traumatic.”
The claim had been previously reviewed by a different vendor using an automated process that identified $10,000 in suspected errors.
HPC’s nurses and professional coders reviewed the claim and discovered that $4,000 of the previously identified errors were in fact valid charges, and would have resulted in an appeal. Further, HPC identified an additional $12,000 in deniable charges not identified through the original automated process.

HPC was able to secure signoff from the provider on the increased savings, resulting in a clean claim that avoided appeals or balance billing.

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