In-Depth Health Claim Review Saves Client Up to $15,000 on Surgery that Fails to Meet Standards for Medical Necessity

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As Cypress Benefit Administrators and its Argus Claim Review Division have reported in the past, medical necessity is becoming an issue consumers need to be aware of when considering their health care needs and reviewing the resulting medical claims. The U.S.-based third party administrator (TPA) specializes in employee benefits and shares a recent case study example where a patient was misdiagnosed and nearly received a $15,000 surgery that wasn’t medically necessary.

Cypress Benefit Administrators
As a patient navigating today’s ever-changing health care system, being proactive is essential. Ask questions and make sure the tests and procedures your providers are ordering are medically necessary.

Health care waste continues to be a growing problem in the U.S. with medical necessity as one of the core issues related to overspending. Today, more than ever before, consumers are undergoing tests, surgeries and procedures that aren’t considered necessary.

The Argus Claim Review division of Cypress Benefit Administrators is working to change this. It aims to proactively prevent these unnecessary medical treatments and uncover other costly health claim discrepancies to save employer-clients from excessive charges.

In a recent example, Argus Claim Review received a health claim that included electrodiagnostic (EDX) testing for a plan member with a resulting primary diagnosis of carpal tunnel syndrome (CTS). After two board-certified medical professionals further reviewed the case, there was insufficient documentation to warrant the EDX testing and the CTS diagnosis was deemed inconclusive.

The bilateral surgery recommended – carrying an average price tag of $10,000 to $15,000 – was also found to be unnecessary.

Tom Doney, president and CEO of employee benefits specialist Cypress Benefit Administrators, said that these types of cases are becoming all too common in the health care industry. “Our medical claim review specialists have always been meticulous about catching the typical coding and billing mistakes, but in recent years, they’ve had to start considering medical necessity as part of the equation.”

Upon seeing the CTS diagnosis and noting the lack of a full neurological exam after referral, an in-depth claim investigation by Cypress’s URAC-accredited partners was prompted by the Argus team. With several years of medical claim review experience, many past cases have shown that clients are commonly misdiagnosed with CTS instead of thoracic outlet syndrome or other conditions that often include similar symptoms.

The first expert, a board-certified neurologist, found that the EDX testing was not medically necessary as there was little description of history and response to more conservative measures like wrist splints or physical therapy.

The second review was done by a physician in orthopedic medicine who determined that the exam and EDX testing showed no definitive signs that the client had CTS.

Doney explained that employers who self-fund their employee benefits need to be extremely vigilant. “If it weren’t for this claim review, our employer-client would have had a surgery that cost thousands of dollars to fix a condition that wasn’t even present,” he said. “The effects go well beyond the price tag – a painful recovery, limited function and lost work time are just a few.” He added, “As a patient navigating today’s ever-changing health care system, being proactive is essential. Ask questions and make sure the tests and procedures your providers are ordering are medically necessary.”

Since starting business in 2000, Cypress Benefit Administrators, a privately held company headquartered in Appleton, Wis., has evolved into more than a third party administrator (TPA) by pioneering the way toward cost containment in health benefits. Cypress is the country’s first TPA to bring claims administration, consumer driven health plans and proven cost control measures together into one package. Its customized employee benefit packages combine an appropriate mix of health insurance options that allow for adaptability to the ever-changing healthcare environment and that make sense for employers of 50 to 18,000+ throughout the United States. For more information on Cypress Benefit Administrators with offices in Portland and Salem, Ore., Omaha, Neb. and Colorado Springs, Col., visit http://www.cypressbenefit.com.

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Tom Doney
Cypress Benefit Administrators
920.968.4613
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Lori Van Handel

920.750.5020
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