Case Archive
Bill Auditing
Ref. # 218301

An elderly woman sued her city's Transportation Authority for all medical expenses arising from an injury to her knee suffered during a slip-and-fall. Her prior medical history included end stage renal failure, diabetes mellitus, coronary artery disease, and degenerative joint disease. During the next two and a half years she underwent two total knee replacements. There were five separate hospitalizations and one extended course of rehabilitation. An attorney for the Transit Authority engaged a review of the expenses by a medQuest physician expert specializing in health-care bill auditing and board-certified in Quality Assurance and Utilization Review. The expert reported there was overcharging throughout the patient's care. Additionally, there were numerous charges related to services or medication that did not relate to the injury. The average cost nationwide of an uncomplicated total knee replacement is $42,000, including pre-operative and post-operative treatment, surgery, prosthesis, hospital charges and inpatient rehabilitation. For her left total knee replacement the patient was charged $63,218 by the hospital--not including physician charges. There were two hemodialysis sessions and other Lab/Chemistry charges related to the patient's diabetes, not the knee replacement. One month later the patient developed an ulcer on her knee, requiring hospitalization for debridement and post-op IV antibiotics. Again, there were Lab charges related to the evaluation of diabetes mellitus and end stage renal diseases. For example, there were charges for medication such as Epoetin, which treats chronic anemia secondary to hemodialysis. During the three-week inpatient rehabilitation there were eight hemodialysis sessions and multiple medications administered for the diabetes mellitus and renal disease. Eighteen months later the patient underwent a right total knee replacement, during which there was similar overcharging as well as non-injury related treatment. Before post-operative rehabilitation, the woman presented to the ER due to intermittent episodes of confusion and possible seizure activity. An EEG was normal and the patient was determined not to be epileptic. This episode of care had no causal connection to the injury, nor did another hospital admission for lower back pain three months later, when X-rays revealed degenerative changes of the lumbosacral spine. Finally, there was an ER Level III visit made out of concern for a myocardial infarction that did not relate to the knee injury or its treatment. Between overcharging and non-applicable care, there was excessive billing exceeding $50,000.

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