Red Flags — Egregious Anesthesia Charges Billed to Member

Background

In this Claims Audit Spotlight, we focus on recent claims where a ClaimDOC auditor raised red flags and asked the same question on both claims — is the anesthesiologist and CRNA really charging this much for their anesthesia services or is this a billing error?

Case 1

A 28-year-old plan member was seen for low back pain and received a percutaneous image-guided injection performed in an ambulatory surgical center (ASC) in Dallas, Texas. A CMS-1500 claim form/electronic equivalent was reported/billed for anesthesia services as follows:

  • CPT code 01938 QY, P3 — (one unit) — anesthesia service time of nine minutes and associated charge of $12,105.00.
  • CPT code 01938 is defined as anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord — lumbar or sacral.
  • Modifier QY depicts the service was performed under medical direction of one CRNA/AA by an anesthesiologist.
  • Modifier P3 depicts a patient with severe systemic disease.

Total Billed Charge: $12,105.00

Traditional Network Pricing: $181.70

ClaimDOC Pricing: $59.83* (67% discount)

Plan Savings: $121.87 

Case 2

Another CMS-1500 claim/electronic equivalent was reported/billed for anesthesia services as follows:

  • CPT code 01938 QX, P3 — (one unit) — anesthesia service time of nine minutes and associated charge of $12,060.00.
  • CPT code 01938 is defined as anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord — lumbar or sacral.
  • Modifier QX depicts the service was performed by a qualified non-physician anesthetist with medical direction by a physician.
  • Modifier P3 depicts a patient with severe systemic disease.

Total Billed Charge: $12,060.00

Traditional Network Pricing: $181.70

ClaimDOC Pricing: $56.53* (69% discount)

Plan Savings: $125.17 

The Takeaway

Egregious billed charges were observed on the above practitioner’s health insurance claims. Total anesthesia charges of $24,165.00 were billed for nine minutes of anesthesia performed by a CRNA under the medical direction of an anesthesiologist.  This total anesthesia charge equates to $2,685.00 for one minute of anesthesia.

While physicians/practitioners may charge any amount they elect for items/services provided, egregious fees and billing errors can complicate matters for members to understand their bills and payments, impact the collection of patient balances, build a reputation of facilities charging high fees, create burdens for patients having no insurance and a host of others.

While coding, billing and the reporting of healthcare services is a complicated process, simple billing errors include the submission of:

  • Incorrect patient information
  • Incorrect provider information
  • Incorrect insurance information
  • Incorrect CPT/HCPCS codes
  • Incorrect modifiers
  • Incorrect diagnosis(es) codes
  • Incorrect quantity units
  • Incorrect anesthesia time
  • Mismatched medical codes
  • Missing codes for procedures or diagnoses
  • Duplicate billing
  • Unbundling of services
  • Egregious charge(s) and
  • Others

Whenever an individual receives a bill and the cost for care seems inappropriate/questionable, an inquiry to the provider and/or health plan should be made to obtain an explanation of the service(s) and corresponding charges.

Our goal at ClaimDOC is to use benchmark charges and costs nationally to negotiate fair and ethical payments. Employers turn to us to seeking to establish fair reimbursement rates for their plans allowing them to save money and provide richer benefits to their employees. A win-win for everyone.

* Based on 2024 Medicare Physician Fee Schedule with markup