In the world of insurance claim reviews, our team has grown accustomed to seeing a wide range of billing irregularities. Some are subtle, like an improperly used modifier here, an unbundled service there. Others are more obvious, such as duplicate charges or unsupported procedures. And then, every so often, we encounter a bill so astonishingly inflated that it feels less like healthcare reimbursement and more like someone accidentally submitted their dream car shopping list.
One particularly memorable case involved cervical facet joint injections performed for pain relief. For the patient, this likely meant an uncomfortable day involving multiple spinal injections. For the provider, however, it apparently represented a remarkable financial opportunity.
The physician billed for four levels of cervical injections using CPT codes 64490, 64491, and two instances of 64492.
For those less immersed in procedural coding, here is the practical breakdown: CPT 64490 covers the first spinal injection level, 64491 covers the second, and 64492 applies to the third and any additional levels. For spinal injections (specifically epidural steroid injections), the standard guideline is a maximum of two levels in one spinal region per session. According to our main federal resource, Centers for Medicare and Medicaid Services (CMS), and medical standards, more than one spinal region should generally not be injected in the same session, with a maximum of four sessions per region within a rolling 12-month period.
In simpler terms, billing extra distinct procedural charges in this scenario was already outside permissible reimbursement structure.
But that was merely the appetizer.
Under the applicable New York State Workers’ Compensation Medical Fee Schedule, reimbursement for these procedures follows multiple procedure payment reduction rules. The primary procedure is reimbursed at full value, while subsequent related procedures are reduced because core physician work, surgical setup, supplies, and associated overhead are already accounted for in the first procedure.
Practice Exercise: Let’s Do the Math.
Using the proper fee schedule, the reimbursement should have been:
- $207.86 for the first level
- $154.95 for the second
- $154.95 for the third/additional level
This brought the total legitimate reimbursement to $517.76.
Reasonable.
Structured.
Compliant.
The provider, however, appeared to have a very different interpretation of acceptable billing practices.
The submitted charges were:
- $58,000 for the first injection
- $38,000 for the second
- $38,000 for the third
- $38,000 for the impermissible fourth charge
Total billed amount?
$172,000.
Yes, you read that correctly.
For a procedure legitimately reimbursable at just over five hundred dollars, the provider sought payment more commonly associated with luxury automobiles, substantial home renovations, or perhaps a modest yacht deposit.
At this point, one must genuinely wonder what happened between reviewing the fee schedule and submitting the claim.
Did someone misplace a decimal point several times?
Did they accidentally use the billing template for a private surgical suite on the moon?
Or was this simply one of those cases where compliance quietly exited the room while ambition took over?
To put this billing in perspective, the requested reimbursement exceeded the legitimate payable amount by more than 33,000 percent.
That is no longer aggressive billing.
That is not coding confusion.
That is not an administrative oversight.
That is the kind of submission that immediately raises SIU-level questions regarding billing integrity, regulatory awareness, and potential fraud.
For insurers and investigators, cases like this highlight why detailed fee audits are essential. Excessive billing is not always hidden behind complex documentation. Sometimes it appears plainly on the face of the claim in numbers so extraordinary they almost feel satirical.
And while humor helps keep us sane when reviewing such submissions, the underlying issue is serious. Overbilling of this scale contributes to systemic waste, drives up costs, and undermines legitimate reimbursement systems designed to balance fair provider payment with regulatory compliance.
At AJHC, our team regularly reviews claims involving egregious fee schedule violations, unsupported charges, and suspicious billing patterns. While some providers may push the boundaries creatively, fee schedules remain grounded in law—not fantasy.
Because when a straightforward cervical injection series with Lidocaine (!) somehow becomes a $172,000 event, the question is no longer simply whether the claim is payable.
The real question becomes:
Who exactly is paying for the Lambo?
And did we choose the wrong profession?