Case Studies
e-MAS MRT Case Study 1
Summary:
Patient presented herself with referral from GP with Right Hypocondrial Pain. Admission Request was sent with no imaging reports and no plan to perform ultrasound but with treatment plan to perform Laparoscopic Cholecystectomy (Gall Bladder Removal).
Medical Review Team Action:
Review of admission request form showed that patient had no chronic illness, claims history showed no prior incidences that could lead to Cholecystitis. Therefore, requested for Ultra Sound of Gall Bladder.
Final Outcome:
Ultrasound report showed no evidence of Gall Bladder inflammation. Liver was normal with no lesions or calculi. Pancreas and Spleen was normal. Patient was treated as outpatient and send home.
Total Saving
Total Saved was a Gall Bladder and RM 7,000.
e-MAS MRT Case Study 2
Summary:
Patient presented himself with epigastric pain and cramping at 5.30 AM. Claims History showed patient has history of cardiac illness. Admission was immediately allowed. Abdomen Ultrasound, X-Ray, ECG, Troponin T was normal.
Medical Review Team Action:
Requested clarification from attending surgeon on need for OGDS for 1 day gastric pain, need for ICU care when all tests were normal and requested for breakdown of RM 30,000 estimation.
Final Outcome:
Patient was treated with IV medication to manage the pain. Specialist cancelled OGDS and Ahesiolysis and discharged the patient the next day.
Total Saving
Avoided invasive procedure and RM 28,000
e-MAS MRT Case Study 3
Summary:
Patient presented himself with shoulder pain and had referral that suggested bicep tendonitis with shoulder flap tear caused by MVA 2 months prior.
Medical Review Team Action:
Approved for Investigation only and requested copy of imaging reports. MRI showed mild riding up of right humeral head, ACJ Arthosis. Patient was advised to treat conservatively with physiotherapy for 3 months before proceeding for surgery.
Final Outcome:
Patient agreed to physiotherapy, and never went back for same injury.
Total Saving
Shoulder reconstruction was avoided.
Up-Coding – Bill Reduced From RM19,750 to RM11,000
This is a classic case of up-coding. Treating doctor had made a claim for ‘reconstruction of the Ear’ - MYR 3410.55 and informed “the ear was beyond recognition”.
Picture showed simple laceration @ MYR 1300.00. Similarly, some very simple wounds measuring about ½ cm to ¾ cm were charged 1300.00.
Doctors charge MYR 100.00 for wound dressings though there is no provision for this. Often there is a pattern of some doctors committing billing errors.
