Nothing feels more unfair than getting a surprise medical bill in the mail without any explanation of what the charges are for or if they are even legitimate. Pair that with the 2.3% increase in medical care prices between February 2022 and February 2023, and the result is a harrowing growth in medical debt for many Americans.
The Journal of the American Medical Association Network reports that in 2020, two-thirds of adults were worried about being able to afford unexpected medical bills, 18% of emergency-room visits resulted in at least one surprise bill, and one in five insured adults received an unexpected medical bill from an out-of-network provider. These numbers not only illustrate the mounting medical debt affecting many Americans, but also underscore the problem of healthcare inflation — which is climbing at an unsustainable rate.
Anna Quarum, Co-Founder and Chief Operations Officer of WellRithms, says medical providers wouldn’t tolerate overdosing patients, so they also shouldn’t tolerate overcharging on medical bills. “We believe that claim care is as important as patient care,” Quarum says, further noting the cumbersome and outdated billing systems of group practice insurance companies. “Bill review is not a standard practice for group health. Cost containment for group health billing is a new specialty. While billing vendors help providers get paid more efficiently, their systems are so complicated and automated that there is opportunity for both intentional and unintentional overcharging.”
No More Surprises
WellRithms and other cost-containment companies act as “Robin Hood” firms, coming to the rescue of patients who do not have the expertise to comb through their medical bills in search of errors. These companies scour patient bills for legal and medical oversights that may result in unnecessary charges on billing statements. Without these reviews, patients may end up being “balance billed,” which means they are responsible for the difference between what their provider charges and what their insurance company will pay.
In January 2022, Congress passed the No Surprises Act, which makes it illegal for providers to bill patients for more than their in-network costs when surprise out-of-network bills arise. In other words, health plans must bill out-of-network services as if they were in-network charges when compiling the patient’s medical statements.
Nonetheless, there is still plenty of opportunity for overcharging, especially since there are default charges programmed into the billing systems used by providers that often get transposed onto patient bills, whether or not those services were rendered. In response to these automatic charges, Quarum says: “WellRithms knows how to look at bills at a line-item level and say to the provider, line-by-line, ‘You tell me where these charges were used.’”
The WellRithms Shield program guarantees that patients will only pay what is fair and accurate. The company is backed by insurance that makes the transfer of all legal and financial responsibilities from the patient to WellRithms possible. This guaranteed protection from the adverse effects of balance billing is one of the reasons the company has become so successful.
“Because of our previous experience in workers’ compensation case law and reimbursement standards, we know how to defend our work,” Quarum says. “We have expertise in all aspects of the medical, legal, and technical facets of bill review services. Our CEO is a physician who also has a medical systems background, and our team has senior engineers that code the algorithms in the software we use.”
This software is the crown jewel of the company’s achievements, since its own team developed the built-in rules for finding automated charges. “In addition, WellRithms takes over the risk of the claim, so if a member is sent to collections or if there is a provider dispute, they deal with us,” Quarum says.
Advocacy Starts Small
Since third-party bill reviewers are typically business-to-business service providers, how can individuals take advantage of this service? The short answer is employee activism.
According to Quarum, employees can put pressure on their employers to work with insurers that contract third-party bill reviewers to audit member statements. Asking employers to be transparent with how they are managing benefits opens the discussion for employee advocacy and support. People often feel like they aren’t knowledgeable enough about the intricacies of medical insurance to rock the boat at work, but questioning the status quo is the only way to bring awareness to the issue and open dialogue.
With such high stakes and so much being left on the table, employees can’t really afford not to advocate for themselves. Large insurance carriers have their size and revenue to protect them from the fallout of questionable billing policies — employees don’t. In order to advocate for themselves, employees can demand transparency and hold providers accountable for unnecessary or overcharged billing.
Knowledge is Key
While having the help of a cost-containment company is ideal, patients can shift the balance of power by arming themselves with knowledge. Experts say the first step is for them to educate themselves on all aspects of their insurance plan — to read the fine print about deductibles, premiums, copays, coinsurance, and any caps that insurers may have set for common procedures.
Similarly, many insurers offer searchable databases that allow members to compare patient costs and discover cheaper options. For instance, many procedures can be performed as an outpatient service rather than an inpatient service, which is typically less costly. Further, after undergoing a procedure or having an overnight hospital stay, patients are advised to ask for an itemized bill before paying anything so all charges can be reviewed for overbilling.
MORE FOR YOU
Employers with a self-funded health plan can be responsive to staff requests to research the benefits of cost-containment companies to ensure accurate and fair reimbursement. Considering WellRithms is a 2022 Inc. 5000 honoree and has been independently validated, it’s not hard to see why it has quickly risen to stardom since its incorporation in 2014.
The success stories on the company’s website illustrate how hundreds of thousands of dollars are shaved off patient medical bills due to catching and correcting automated billing errors. One example involved reducing charges for a cervical arthroplasty procedure by 90%, or $132,729.00.
For many patients, appropriate medical coding and correctness can mean the difference between good financial health and unnecessary medical debt. Enlisting the help of companies such as WellRithms is a powerful way for employers to protect their employees while also defining their priorities in terms of corporate wellness initiatives. Cost-containment agencies save both patients and employers money, which can be reinvested into broader corporate health outcomes in the long run.