What a late bill-only request costs, line by line

Every name and figure here is invented: the hospital, the supplier, the surgeon and the rep, the catalog numbers, the prices and the minutes. The shape of the costs is not. It is the shape of any bill-only request that arrives late, on paper, with a price nobody checked, and the method is for putting your own figures in.

The request

An ORIF of the left distal tibia at North Campus on a Tuesday, Dr. R. K. operating, case EX-20431. Calderwyn Ortho’s rep, J. D., brought the tray. Seven lines were implanted.

Line	Catalog	Item	Qty	Contract price	Line total
1	CW-127-241	Distal tibia locking plate, 8-hole, left	1	$1,480.00	$1,480.00
2	CW-127-305	Locking screw, 3.5 x 40 mm	4	$96.00	$384.00
3	CW-127-318	Locking screw, 3.5 x 46 mm	2	$96.00	$192.00
4	CW-127-402	Cortical screw, 3.5 x 36 mm	2	$62.00	$124.00
5	CW-128-110	Syndesmotic screw, 4.0 x 50 mm	1	$118.00	$118.00
6	CW-129-077	Guide wire, 2.0 mm	2	$24.00	$48.00
7	CW-130-015	Washer, 3.5 mm	2	$18.00	$36.00
		Total at contract			$2,382.00

At contract, the case is $2,382.00. The rep’s sheet carries the plate at $1,492.40, the price from last year’s tier, so the sheet totals $2,394.40. One line, $12.40 over. Hold on to that figure. It is the smallest number in this article, and the whole first path is spent on it.

Path one: six days late, on paper

Day 0, Tuesday. Surgery. The circulating nurse records the implants in the EMR. The rep writes a sticker sheet and takes it away in the tray.

Day 6, the following Monday. A photograph of the sticker sheet arrives by email at the OR business office. The coordinator keys the header and seven lines into a requisition from the photo: 20 minutes. Two catalog numbers do not resolve on the first try, because the sticker reads CW127241 and the item master reads CW-127-241, and another 10 minutes goes on that. The request is already late and the rep is asking for a PO, so the comparison against the EMR implant log is skipped. This is the quiet cost of a manual check: it is the one that gets dropped under pressure, and the one that would catch a quantity error.

Day 8. The buyer prices the requisition from the item master, so the PO goes out at $2,382.00: 15 minutes.

Day 12. The invoice arrives at $2,394.40. The three-way match fails by $12.40.

Days 13 to 34. The exception works its way around. AP emails the buyer, the buyer emails the rep, the rep replies that $1,492.40 is the price, contracting pulls the agreement and confirms $1,480.00, supplier billing issues a credit memo for the invoice and a rebill at the right amount, and AP processes both. Three departments, four handoffs with a few days’ wait at each, and about 60 minutes of hospital time.

Day 64. The rebill is paid on 30-day terms.

In between, the rep has sent three emails and made one call asking where the PO was, and then where the payment was. Answering them took 15 minutes. And because the surgery was on the 26th and the PO was written in the following month, finance either estimated the implant expense at month end or carried it in the wrong period: call it five minutes and a wrong number.

Hospital staff time on the first path, at a flat $1 a minute to keep the arithmetic visible: about 125 minutes, $125, to recover a $12.40 variance, over 64 days. The supplier spent its own time too: a rep chasing, a billing clerk issuing a credit and a rebill, and a receivable that aged two months.

Path two: structured, and checked before the PO

Day 0, Tuesday. Surgery. Same EMR record.

Day 1. The rep signs in to the hospital’s request form and files against case EX-20431: date, hospital, surgeon, procedure. Each line is picked from the hospital’s contract catalog for Calderwyn Ortho, so the plate comes in at $1,480.00. The $12.40 never exists, because the price was never typed. The catalog numbers are the hospital’s own, so there is nothing to resolve, and nothing is re-keyed, because the data is entered once by the person who has it.

Day 1, later. The request is compared line by line with the EMR implant record: seven catalog numbers, seven quantities, all present. The approver sees a clean match and confirms it: 10 minutes.

Day 2. The requisition goes to the ERP on the scheduled file, and the PO number comes back.

Day 6. The invoice arrives at $2,382.00 and matches the PO without anyone touching it.

Day 36. Paid on terms.

Hospital staff time: about 10 minutes, nearly all of it the approver’s. Rep follow-ups: none, because the status and then the PO number were visible to the rep from the start. The implant expense lands in the month of the surgery, with a PO behind it.

Side by side

	Late, on paper	Structured, checked first
Request received	Day 6	Day 1
Re-keying	Seven lines, from a photograph	None
Price on the request	The rep’s price list	The contract
Case check	Skipped	Done, line by line
PO issued	Day 8	Day 2
Variance found	Day 12, at the invoice	Never exists
Credit and rebill	Yes, 21 days	None
Invoice paid	Day 64	Day 36
Hospital staff time	About 125 minutes	About 10 minutes
Rep follow-ups	Four	None

What the $12.40 was hiding

The variance is not the cost. The handling is, and it is the same handling whether the variance is $12.40 or $1,240. A line that is wrong after the invoice costs a match exception, a credit, a rebill and a month, regardless of the amount. A line that is wrong while the request is still pending costs one message to the rep.

The second thing the $12.40 hides is the check that was skipped. The first path caught the price only because the buyer happened to price the PO from the item master. It never compared the seven lines with the case record. A fifth screw, or a plate that was opened and not implanted, would have gone through at full price, and nothing in the first path would have known.

The third is the window. A request filed on day 6 cannot be filed on day 1 by anyone at the hospital. Only the rep can move it, and only a rule the rep meets at submission moves it reliably: write the window into the supplier agreement, show it on the form, require a written reason past it, and refuse it beyond a limit.

Work it out on your own numbers

Put in your own figures: minutes per re-key, your loaded hourly rate, your share of requests that arrive late or off contract, your days from surgery to PO. The bill-only request cost worksheet does the arithmetic in your browser. For the process behind the second path, read the bill-only workflow explained and how to price-check a request before it becomes a PO. Implant Control is the second path as software: the rep files against the real surgery, every line is checked against the contract price list and the case record before the PO, and the workflow ends when the PO number comes back.