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In-Depth Health Claim Review Saves Client Up to $15,000 on Surgery that Fails to Meet Standards for Medical Necessity
Date:9/30/2013

Appleton, WI (PRWEB) September 30, 2013

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 revie
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