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[Changemakers] Why every self-insured employer needs fraud protection ft. WellRithms


This post was written in partnership with WellRithms.

Despite new hospital fair-pricing regulations, fraudulent and wasteful medical billing is still overwhelming self-insured employers and their employees. In our first Flume Healthcare Changemakers webinar, we spoke with two experts from Wellrithms, a firm that specializes in detecting and eliminating erroneous and abusive billing practices. 

When insurers and self-insured employers create their health plan, building in fraud and abuse protection is imperative. 

There are several categories where employers and employees face high-cost claims, said Dr. Ira Weintraub, chief medical officer of Wellrithms. 

Weintraub said that any surgery procedure needs “very specific medical review.” 

“Sometimes the simplest surgery in the world, a hospital will over bill,” he said. “We have seen hernia repairs billed at $136,000 for an outpatient hospital.”

This is especially true with implants, when individual tools and prosthetics are used. In order to understand the medical bill, he said, you need to understand the medicine. This is why it’s especially important to have expert reviewers. 

“Who makes that decision to mark up an implant cost five times market value?” he said. “The answer is, nobody really knows. We do know that implants need to be scrutinized.” 

Weintraub said that other common areas of markup are premature birth and neonatal intensive care. 

While new healthcare pricing regulations have good intentions, they aren’t necessarily lowering patient and employer costs. 

“The hospital price transparency regulation sounds like a good idea on paper,” said Matthew Jacobs, chief business development officer of Wellrithms. “It is designed to empower patients to make good decisions on where they go for treatment.”

“The problem is, most of the hospitals are not compliant. And the ones that are, the data that they’re putting out there is so convoluted and messy … you can’t figure it out,” he said. 

Potential benefits of the No Surprises Act will be seen once the regulation comes into effect in 2022. The act aims to end surprise medical billing.