The $167,249.79 Dream

Mary, a 56 year old working mother has a bad back. Her doctor recommended surgery. As she lay unconscious on the operating table little did Mary know the man in a mask lurking behind the surgeon was dreaming of a big payday.

The man in the mask was the assistant surgeon.

The date of service was less than 30 days ago but the assistant surgeon’s billing department wasted no time in submitting his bill for services rendered. Below is a redacted copy of the claim.

Mary’s self-funded health plan is administered by an independent third party administrator (TPA) which closely monitors and audits all claims for Mary’s employer.

“Here is the claim. It is unbelievable. This assistant surgeon is billing $167,249.79.  The allowed amount is $5,369.28. – which would make this about 3700% of Medicare” – Third Party Administrator note to

The man in the mask dreaming of a big payday can dream all he wants. When we gently wake him and break the news that dreams don’t always come true we will be sure to have enough standing by for an appropriate intervention.

NOTE: The diagnosis code/s are M5126, M4696, M48061. CPT Code/s are 63047, 22633, 22634, 22842, 20937 is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and fairness in direct reimbursement compensation methods.