Case 1
PATIENT: Newborn baby girl
CONDITION: Multiple congenital conditions
CHARGES: $6,301,562.10
DENIED CHARGES: $1,905,568.47
PROVIDER: HOSPITAL IN ILLINOIS
This patient was admitted to paediatric ICU for congenital diaphragmatic hernia, respiratory failure, lung hypoplasia and dysplasia, and atrial septal defect. The patient has experienced cardiogenic shock, convulsions, Staphylococcus sepsis, UTI, pneumonia, atrial septal defect, cerebral ischemia, acute tracheitis, dysphagia and GERD during her hospital stay. Procedures performed on the patient are diaphragmatic hernia repair, ECMO, gastrostomy tube placement and lysis of adhesions, tracheostomy tube placement and exchange, multiple endotracheal intubations and replacements, and central line placement.
AF24’s line item review of this high dollar claim revealed that nearly $2M of total charges (approx. 30% of total billed charges) were unbundled items such as common supplies (e.g. saline, distilled water) and routine services such as blood draws and respiratory services, all of which should be included in room and board or operative room charges.
Case 2
PATIENT: 56 year old female
CONDITION: Severe respiratory distress
CHARGES: $1,327,584.25
DENIED CHARGES: $203,939.31
PROVIDER: HOSPITAL OF INDIANA
A 56 year old female patient with a history of anxiety, cardiomyopathy, and multiple respiratory illnesses. The patient presented to the emergency department on 11/17/2022 after 3 days of progressively worsening shortness of breath and a productive cough. The patient was the admitted to the ICU with acute respiratory failure and an exacerbation of COPD. Shortly after admission, the patient developed hypoxia and sepsis with shock, and was found to have multi-drug resistant pseudomonas. There were very little treatment options because the patient would eventually develop resistance. Cardiology was consulted regarding the patient's cardiomyopathy and the concern for a possible STEMI heart attack. The patient's respiratory symptoms did not improve, therefore a tracheostomy and PEG tube were placed. The patient and husband declined a referral to palliative care, so the decision was made to transfer the patient to an LTAC facility for further acute care and rehabilitation. She was transferred on 12/31/2022 in stable condition. Total inpatient stay was 44 days.
AF24’s line item review identified multiple sources of bill inflation, including charges normally included in room and board, nurse services, duplicate charges as well as services not supported by the medical documentation.
Case 3
PATIENT: 31 year old male
CONDITION: Covid-19
CHARGES: $1,615,011.01
DENIED CHARGES: $256,443.35
PROVIDER: HOSPITAL IN TEXAS
The patient with history of severe obesity (BMI 50 - 59.9), presented to the emergency department on 12/12/2021 for acute respiratory distress syndrome and was positive for Covid-19. Initially the patient was admitted to the medical/surgical unit for sepsis and pneumonia secondary to Covid-19, but was transferred to the intensive care unit the following day. The patient's condition continued to deteriorate and he required intubation and ventilation. During the hospital course, the patient had multiple bronchoscopies in which the right middle and lower lung lobes were drained as well as the right and left main bronchi. The patient developed multiple pressure ulcers (stage 3) of the head, sacral region and both buttocks as well as acute embolism/thrombosis of the right femoral vein and bilateral popliteal vein. Due to the patient's critical condition and guarded prognosis, his resuscitation status was changed to do not resuscitate (DNR) and he was referred to palliative care. Total inpatient stay was 59 days.
In addition to the $172k of unbundled charges normally included in room/board and ICU charges, AF24’s line review identified 64K of charges completely unsupported by the medical documentation, as well as $20k of professional fees that should not be billed on a facility claim but rather billed out as separate professional fees.