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How Different Is Expert Witness Testimony From An Ordinary Witness Testimony

Mon, 30 Jan 2023 10:49:48 GMT

Witnesses play one of the most important parts in all kinds of cases - from criminal to personal injury . They help clarify what happened by revealing the information about the matters of the case to the judge or the jury.

Whenever someone answers a question under oath during a trial or a deposition, they are considered by the law as witnesses and the statements they make are considered testimony.

However, not every witness is the same. There are two types - expert witnesses and ordinary (or lay) witnesses. This fact affects whether the testimony will be permissible as evidence.

Today, we’ll take a deeper look at both types of witnesses and explain what expert witness testimony is and how it differs from regular testimony.

What Is Lay Witness Testimony?

These witnesses are often in close relation to the case. For instance, they may be business partners of one of the parties, family members, or more commonly, eyewitnesses that were present on the scene.

The lay testimony is governed by the Federal Rule of Evidence 701, under which lay testimony must be:

1. Based rationally on the perception of the witness

2. Helpful for determining the facts of the case

3. Not based on specialized, technical, or scientific knowledge

According to the law, ordinary witnesses can only testify about their firsthand knowledge of the facts of the case. This means they can only relay information to the court that they have gained through personal knowledge or perception that is rationally based.

Since they can testify in different matters, the definition of what constitutes personal knowledge can be comprehensive. Typically, an observation of an event does fall within the realm of what can be defined as personal knowledge.

This could be a firsthand account of a car accident or a crime.

Additionally, lay witnesses are allowed to testify about their perception of the events in the case if they obtained the perception through earlier observation. For example, they can offer an opinion about a person’s appearance, degrees of light, distance, etc.

These perceptions must be based on rationality, but the standard here isn’t that strict as lay witnesses are allowed to use everyday logic to come to conclusions in their testimony.

Normally, lay witness testimony and opinions don’t need to be summarized or disclosed before the trial commences. The only exception is when the regular testimony starts threading the line between a lay and an expert witness testimony. In those cases, the lawyer has to ensure that testimony can be admissible in court.

For instance, they may disclose the opinion of the witness to the other party or strike up an agreement with them about the disclosures they need to provide.

What Is Expert Witness Testimony?

An expert witness is an individual who has experience and skill sets that can help the jury or the judge understand the factual evidence of the case.

Since these individuals don’t have immediate knowledge of the events that transpired, they use their expert methodologies and technical knowledge to form a reasonable opinion on the case.

Expert witness testimony is governed by the Federal Rule of Evidence 702 which sets out different standards than in lay testimony. An expert opinion is only admissible in court if it was supplied by a witness that is qualified as an expert and has training, education, experience, knowledge, or skill.

Furthermore, according to Rule 702, the expert witness testimony has to meet the following requirements:

1. Knowledge of the expert can help the judge or the jury determine a fact or understand the evidence

2. Expert witness testimony is based on data and facts

3. Testimony was produced through reliable methods

4. Expert has applied all the methods and principles to the evidence or facts

While this rule seems restrictive, experts can still provide their own opinion. For instance, they may testify about generally accepted principles, information, or methods if they are relevant to the case matter.

Standards Applied To Expert Witness Testimony

The standards are usually higher for expert witness testimony. For example, according to Federal Rules of Civil Procedure that apply to most states, lawyers have to meet disclosure requirements that aren’t required for regular witness testimony.

Rule 26(a)(2) dictates that experts retained by attorneys must submit an expert witness report (this rule sometimes applies to consulting or non-testifying experts).

An expert may also be deposed by the opposing party. The questions in this deposition usually clarify the qualifications, methodology, and key assumptions outlined in the expert witness report.

The opposing party can also use the deposition as a chance to condense the scope of the testimony by establishing the topics that the expert won’t testify about during the trial.

Anything an expert reveals or says during the deposition can be potentially used to impeach them later on. This means that the testimony can’t be inconsistent with the testimony at the trial.

In most cases, the judge will be tasked with applying the Daubert standard to establish if the expert witness testimony is properly applied to the issue at hand and if the testimony uses valid scientific reasoning.

More precisely, the judge will determine the following:

1. If theories or techniques from the expert witness testimony can be tested

2. Whether the theories or techniques have been peer-reviewed

3. If there are necessary standards that the techniques adhere to

4. Whether the scientific community accepts the theories/techniques

Retaining An Expert Witness

Experts can fill many roles in the litigation process, but more often than not, they are considered either consulting or testifying experts. The former are usually retained by one of the parties in anticipation of a legal process while the latter may present evidence at the trials.

In other words, consulting experts help attorneys prepare the best case possible.

Since expert witness testimony is usually put under a great deal of scrutiny and their qualifications are contested, your choice of expert matters. Choose only an expert witness that has experience in the area related to the case.

You should also review their prior testimony to see if they were previously disqualified in a similar case. If that’s the case, they’re not a good choice as their disqualification will be raised as a point in the trial.

What Does A Medical Billing Specialist Do?

Mon, 23 Jan 2023 12:08:55 GMT

The most important behind-the-scenes process in every medical facility is medical billing and coding for patient invoices and insurance. But who are the individuals who complete this task?

In some cases, office managers and physicians may stretch themselves thin by taking on this role.Typically, medical providers will hire a medical billing specialist or a medical coder to fulfill this role.

That way, physicians can focus on providing the best care possible while trained specialists take on the most important administrative role in the ecosystem of a medical institution.

Here’s a detailed breakdown of the medical billing specialist (aka medical coder) role.

The Role Of Billers And Coders

A medical billing specialist bridges the gap between a medical institution and insurance companies. In other words, this individual manages payments, invoices, and insurance claims on the behalf of the organization they work for.

Billers and coders usually do the following:

1. Code services, diagnoses, treatments, and procedures

2. Prepare and send out invoices and payment claims

3. Correct rejected claims and track payments

4. Communicate with insurance companies and patients to receive outstanding bills

Even though these professionals work in the same facility as physicians, most patients will never come in contact with them. It’s purely an office job that takes place in the background.

Are Coding And Billing Different?

While the job description is similar and a medical billing specialist may also do coding, the positions are quite different and have unique sets of responsibilities.

With small medical offices, it’s standard practice to hire either specialist to perform both roles. In larger facilities, the roles are separate and both coders and billers work together to ensure the process of coding runs smoothly. This also helps medical providers avoid costly billing and coding errors whileensuring payments are collected on time.

In a larger facility, the division of labor between the two may look something like this:

Medical Coders

The main responsibility of coders is converting procedural and diagnostic notes into codes for billing and record-tracking purposes. These are industry-standard codes that identify provided and billed medical services.

Medical coders require a different set of knowledge of the following codes:

1. International Classification of Diseases (ICD-10) - classification of medical diagnoses

2. Current Procedural Terminology (CPT) - codes that identify procedures and examinations, and are updated annually

3. Healthcare Common Procedure Coding System (HCPCS) - codes not included in the other two sets of codes that normally cover non-physician services, medical supplies, and devices

A coder may enter these codes when a patient books an appointment. Then they’ll code for the symptoms and the type of visit. Afterward, they will apply additional codes for symptoms described by physicians, as well as tests, diagnoses, procedures, and recommended treatments.

Medical Billers

After coders have completed their job, medical billers take over. They generate invoices and send the claims to payers. Insurance companies will then approve or deny the requests based on the provided codes. The costs not covered by insurance are then forwarded to the patient.

The billing process itself starts when the patient makes an appointment and billers submit codes for pre-approval. This is done to determine the patient’s out-of-pocket expenses, allowing the medical provider to charge the amount during the visit.

The reason why a medical billing specialist is often interchangeable with the coder is the fact that the biller also needs a deep understanding of industry codes. Even in cases where the roles are separate, the biller is in charge of updating the codes and reviewing the reasons behind denied insurance claims. More importantly, they also need to verify if the codes are correct before filing any claims.

Furthermore, the medical billing specialist is in charge of invoicing patients when insurance billing is complete. They track payments, follow up on due payments, and determine copay amounts and requirements.

If the bill is unpaid, billers have to reach out to insurance companies to check if the paperwork requires updating. They’ll also reach out to patients if they failed to submit payments for outstanding bills within a specific timeframe.

Required Skills

The basic requirements for both roles are generally the same. The most important skill is deep knowledge and experience with up-to-date codes. There are additional skills that help distinguish a bad specialist from a good specialist, such as:

1. An understanding of medical terminology

Coding and billing are significantly easier when the staff is familiar with basic medical terms. This may include knowledge of physiology and anatomy terminology, as well as familiarity with procedural and diagnosis terminology.

2. Mathematical skills

Medical coding is all about numbers, so it’s essential to be able to do basic arithmetic calculations to calculate the right billing amounts. In today’s day and age, we have access to billing software systems that automatically fill out the forms with correct amounts based on the medical codes. However, this doesn’t mean there are absolutely no calculations. Medical billers, for example, usually manually calculate the patient’s amount of due payments or quantify payment plans.

3. Computer skills

To be able to successfully fulfill these roles, coders and billers need to know medical software and computer systems used in medical institutions. They also must learn to use new software fast in case there’s an upgrade or switch.

4. Communication skills

In addition to the above, medical billers need to possess a high level of communication skills since their tasks include contacting patients and insurance representatives. They should be able to effectively communicate with patients who may be going through a lot of stress when dealing with their medical bills.

Medical Billing Specialist As An Expert Witness

Medical billers and coding specialists may also offer their services as expert witnesses. They can provide expert opinions in cases of Medicaid and Medicare abuse and fraud, along with reviewing bills and records to determine if the charges are reasonable.

They may also put together witness reports about all sorts of billing claims, and explain benefits and copays.

Both plaintiffs and defendants can leverage the services of these experts to determine the right costs of medical care, and ensure the jury and the judge have the right understanding that the charges are fair and reasonable.

Why Go For Medical Billing Analysts?

If your case involves any dispute over medical billing codes, you should hire an expert that can provide you with an evaluation of your medical charges.

With an MBA on your team, the discovery and research during your complex medical phase will go a lot smoother. You can focus on the fine legal details while we analyze the medical bills and help determine the fair and reasonable charges.

Contact MBA now by calling (800) 292-1919 , and build a stronger case!

Why A Medical Malpractice Expert Witness Is Important For Your Case?

Mon, 16 Jan 2023 12:12:08 GMT

While all personal injury cases are complicated, medical malpractice cases are on a whole different level. Just compare a clear-cut slip and fall to a medical case, and you get the picture.

Because the jury consists of ordinary people, they may need help understanding the nuances of the medical profession. This is why a plaintiff needs to hire a medical malpractice expert witness - an individual who can explain the complex medical terminology to the jury and the judge, thus aiding them in reaching a fair decision.

Here’s why a medical malpractice expert witness plays a crucial role in the success of your case.

Who Are Medical Expert Witnesses?

Medical malpractice expert witness is a professional with relevant experience and education that enables them to offer a professional opinion on the case. To put it differently, they can determine whether a medical professional violated the standards of care which directly led to the plaintiff’s injuries.

Typically, legal teams from both sides will consult their own expert witnesses, but it’s also possible for a medical malpractice expert witness to be a neutral expert in the case. This means they’re not testifying on behalf of either of the parties in the trial, rather, they are simply providing their opinion on what happened based strictly on the facts presented in the case. They’ll answer questions from both the defense and the plaintiff, then offer their professional opinion on the events.

Medical expert witnesses can help plaintiffs achieve victory in medical malpractice cases by providing insight if medical malpractice occurred, and they also significantly strengthen the cases.

As a matter of fact, they’re necessary for most circumstances as they’re the only ones who can prove negligence.

Do You Need A Medical Expert Witness For Each Case?

In most medical malpractice cases , there will be an expert witness. That is unless the case is clear-cut with overwhelming evidence that supports the plaintiff’s case. If a doctor's misconduct is obvious, a jury may not need an expert to gain insight into how the medical professional violated the standards of care.

For example, if a surgeon left a foreign object in their patient’s body or amputated the wrong limb, they have committed malpractice and no jury will dispute that.

Additionally, if no one other than the medical professionals can be responsible for causing the harm, the res ipsa loquitur rule comes into effect. This rule means that the causation is evident or when translated directly - the thing speaks for itself.

Can Everyone Be An Expert Witness?

A medical malpractice expert witness should have the qualifications relevant to the case. For example, if a plaintiff is suing a doctor for wrongful birth, the expert you hire should have expertise in that medical field so they can testify if prenatal testing was necessary.

On the other hand, if you’re involved in the case of medical billing or fraud, you have to hire a witness who is an expert in medical billing or coding, such as the experts working in our company - MBA .

Naturally, some expert witnesses specialize in other types of malpractice cases, such as:

1. Obstetricians

2. Radiation oncologists

3. Pediatric specialists

4. Emergency medical technicians

5. Emergency room physicians

As a rule of thumb, always hire someone who specializes in the area relevant to your circumstances.

How An Expert Helps You Prove Negligence

With their testimony, a medical malpractice expert witness can help the jury understand if medical malpractice occurred.

They will explain exactly how a medical professional failed to meet the standards of care and how their mistakes led to the plaintiff’s injuries. Their testimony will provide the necessary context and will describe in detail the procedures and practices performed by another doctor from the same field.

This helps illustrate how the defendant deviated from established norms.

For their testimony, the expert may rely on their own knowledge, but if needed, they can also quote industry standards and academic publications to strengthen their claims.

When it comes to establishing causation, the expert has to address different factors that may have led to the plaintiff’s injuries. They can then explain that the evidence may suggest that negligence directly contributed to the injury or was the main cause.

Even if your client fails to identify a key detail, a medical malpractice expert witness can help spot any piece of information that might have fallen through the cracks. Who knows, this might be the crucial piece of evidence that wins the case.

For instance, a plaintiff might not be aware that their doctor should have performed a different procedure or didn’t order a test that’s standard practice in the situation. These are important facts that reveal that the doctor had the opportunity to avoid making a mistake but didn’t, for whatever reason.

Additionally, a medical malpractice expert witness can uncover different evidence of negligence such as failure to meet standards of care, any deviations from a standard protocol, or even breaches of informed consent.

Finding The Right Expert

If you determine that the case you’re working on requires expert testimony, you need to retain an expert before the case even goes to trial. In most states, you also need to consult an expert witness for an affidavit of merit that you’ll need before filing a legal complaint.

Normally, the defense will also retain its own expert. This means you and the opposing party need to disclose to the court what your expert will testify in the trial.

While not every expert witness is a practicing doctor (they can be certified in the field or be a professor), you should still hire someone who has spent some time practicing in the field.

In some states, there are procedural rules that allow experts to testify only if they recently spent some time actively practicing medicine. This helps ensure that doctors can’t make a career out of being expert witnesses.

Win Your Cases By Leveraging The Best Experts

Medical malpractice cases are intricate, so you should always have an expert on board. This also goes for situations where retaining someone seems redundant - who knows, maybe you overlooked a fact that will solidify your client’s case even further.

If your case involves a large number of medical bills, you should do yourself a favor and hire a medical expert witness that has a deep level of knowledge of CPT codes.

Contact MBA now by calling (800) 292-1919 , and we can put together a comprehensive report, review all medical bills, and verify if they’re valid.

Why Lawyers Work With Medical Expert Witness Companies?

Mon, 09 Jan 2023 10:06:04 GMT

If you’re looking to file a medical malpractice lawsuit, you probably heard about medical expert witness companies. These experts are an integral part of medical malpractice claims which have a specific set of rules.

In most cases, your lawyer will work with one of the medical expert witness companies they choose because that’s the only way to file a lawsuit.

Here’s what you should know about these experts and the importance of their testimonies.

Why Is This Testimony Required?

Typically, plaintiffs are required by the law to have testimony from a medical expert before even filing a lawsuit.

Why?

Since the medical field is very complex, you’ll need expert help in proving the following:

1. You were under the care of the medical professional you’re suing

2. The medical professional in question was negligent or provided care that isn’t up to the medical standards.

3. The substandard care contributed to your injuries

4. You suffered specific types of damages due to these injuries

These four elements form the basis of a medical malpractice suit. Since your lawyer is not well versed in the medical field., and nor are you. This is why you’ll need help from medical expert witness companies who will send one of their experts to help you prove these elements.

The most important part is establishing the standard of care in the specific type of circumstances and proving how the defendant provided care below that standard. In other words, only an expert is competent enough to claim a physician or other professional didn’t show standards that another professional would have shown under identical circumstances.

Additionally, a medical expert has the necessary knowledge to claim with certainty that the substandard care contributed to your injuries.

However, even though they are in the medical field, the defendant may also leverage services from one of the medical expert witness companies to defend their position. To put it differently, their expert will claim that the care their client provided was in line with the medical standards.

This position is usually referred to as the battle of the experts, and sometimes, medical malpractice cases are won on the merits of an expert’s credibility.

Who Are Medical Expert Witnesses?

Generally, an expert you hire should come from the same field as the medical professional you’re pressing charges against. For instance, if you’re suing someone for a surgical error, not just any physician will suffice, you’ll need a surgeon’s testimony.

Medical expert witnesses come from different branches. They can be physicians, nurses, and other professionals such as surgeons or medical billing specialists.

When choosing an expert, you should go with an expert still actively practicing medicine. These individuals will be up-to-date on the latest standards of care, and their testimony will simply be more credible.

Additional qualifications may include board certifications, publications in medical journals, experience with providing testimony, as well as experience with creating affidavits of merit.

It’s also worth noting that in some cases a medical expert witness doesn’t have to be a medical provider. For instance, if you’re pressing charges for the wrong medication, you’ll need expert testimony from a pharmacist. Or if you’re suing a medical provider for a billing error or a billing fraud, you’ll need an expert on medical billing (for example we’re one of the best medical expert witness companies specializing in medical billing ).

What Does A Medical Testimony Include?

The testimony of a medical expert will provide an answer to the two crucial questions:

1. The standard of care

Your medical expert will testify about the actions that a competent medical provider would have done if they were met with similar circumstances. For instance, if a doctor didn’t provide the correct diagnosis, the expert will testify about what a doctor with the same credentials would have done instead when presented with the same set of symptoms.

If there is a mismatch between the two, the expert will conclude that the standards of care weren’t met by the defendant.

2. The causation

After the failure to meet standards of care was established your expert will testify how it contributed to your injuries. This is especially challenging since proving causation can be difficult.

For example, it’s very hard to determine if the defendant’s action led to the bad outcome or were the injuries simply caused due to the condition the defendant was treating.

This is why an expert is crucial, as only they can link the injury to a physician's failure to meet the standards of care.

Can You File A Malpractice Lawsuit Without A Lawyer Or A Medical Expert Witness?

Medical malpractice lawsuits are not simple workers comp’ cases. You need a deep understanding of legal, as well as different medical issues. There are also more rules you need to be familiar with.

Regarding an expert, in many states, you’ll need an expert witness testimony before even filing your suit. Your lawyer will advise you on which expert you should choose. They may rely on medical expert witness companies, but they may also have a contact list full of experts they worked with on previous cases.

It’s important to note that in specific circumstances, you may not even need a medical expert witness. This usually applies to medical errors that are obvious enough for every juror to understand. For instance, if a surgeon leaves a medical instrument inside a patient’s body, you don’t need to be a doctor to realize this is malpractice.

This rule is referred to as ‘’res ipsa loquitur’’ (the thing speaks for itself). Nevertheless, you need to prove the following:

1. You were harmed while under the care of the defendant

2. The injury wouldn’t have happened if the defendant wasn’t negligent

3. You didn’t contribute to the injury.

In conclusion, you’ll need a lawyer and your lawyer should determine if res ipsa loquitur applies to your malpractice case.

Wrapping Up

A medical expert witness is necessary for most malpractice cases, so you’re bound to talk to one sooner or later.

When filing your claim, make sure that you talk to an experienced malpractice lawyer who will help clarify the facts of your case and help you determine whether your case needs a medical expert witness.

Then, they’ll connect with one of the medical expert witness companies or bring their trusted witness on board. Ultimately, together, they’ll help win your case and recover your well-deserved settlement.

How To Draft a Rebuttal Letter

Mon, 02 Jan 2023 11:55:42 GMT

Regardless of your background, one of these days you’ll be in a situation where you’ll have to defend yourself against someone’s opinion: your employer reprimanded you or maybe even your medical claim got denied by the insurance company .

That’s not the end of the world, as you can still change things around by drafting a rebuttal letter.

These letters are formally written and express arguments and terms of your rebuttal. You can use these documents to address any allegations or express your disagreement with someone’s decision, among other things.

Here’s how to draft a rebuttal letter.

The Structure Of A Rebuttal Letter

Writing anything is easy once you get the structure down. Thankfully, most rebuttal letters follow a similar format.

1. The addressed

The first thing is always the name of the address (aka the person you’re writing the letter to).

2. The date

You should always date any written communications, and a rebuttal letter is no different. Keep in mind that you should be truthful, so include the exact date when you wrote the letter.

3. Body

This is the meat of your rebuttal letter and the part containing the arguments you’re using to counter the allegation/accusation/denial. Since this isn’t a demonstration of your creativity, keep the text short and courteous.

4. Name and signature

To close out the letter, you have to write your name at the bottom. This proves that you’re the author of the letter and that you agree with the statements it contains. Make sure to include your signature between the name and the closing remarks.

5. List of enclosures

If you include any additional documents in your letter, add a list of enclosures that notes down the materials you attached. For instance, if you’re writing an insurance claim denial, you might want to include a physician’s letter that explains the necessity of your procedure.

Drafting a Rebuttal Letter

In this type of letter, you should never beat around the bush. Start by identifying yourself and drawing a connection between you and the other party. The person reading the letter may not be aware of who you are at first, so you should clear up any ambiguities as soon as possible.

When you get to the second paragraph, officially deny the allegation or express your disagreement with a decision. Make sure to provide evidence that backs up your opinion.

In the final paragraph, clarify what your request is. Is it a refund, reconsideration, or review of an entire letter?

Sign the letter, add the date, and you’re done.

You should never let your emotions get the best of you when drafting a rebuttal letter. Stay professional throughout and address only the specific points you don’t agree with. Don’t be vague but simply provide evidence.

For example, don’t write:

I’m not late all the time.

Try this instead:

You stated that I frequently arrive late, yet, the timesheet I attached demonstrates I was late just twice when meetings ran too long.

Most importantly, don’t make excuses if you don’t have the evidence to back them up! Let’s say that something out of your control happened and led to a reprimand - simply define the issue and what you did to rectify the situation.

Sample Rebuttal Letters

To give you a better idea of how these letters should look like, we’ll provide you with two samples for two different scenarios: an employer rebuttal letter and an appeal letter for a claim denial.

1. An employer rebuttal letter

Example Company

Address

City

Date

Dear ______ ,

I have received your evaluation of my performance for the past year. I do have grievances about the contents of the review, though. I do not agree with your statement that my performance was unsatisfactory this year.

I want you to consider the following: I was ill and missed two months of work, which had a severe impact on my overall work performance. I have also spent the majority of this year training ______.

In light of this information that you might have overlooked, I ask you to consider revising the evaluations. I hope we can resolve the issue amicably.

Sincerely,

(Your name and signature)

2. Insurance rebuttal letter

Appeal letters are usually a lot more complex, but you can use the following example as a starting point:

Name of the insurance company

Name of the department

Address

City

Date

To whom it may concern at (name of the company).

My name is _____ and I am a policyholder of (name of the company). I want to file an appeal about your denial of claim for (name of the procedure). In the Explanation of Benefits dated (date of denial), it states (quote the reason directly).

I was diagnosed with (condition) on (date of diagnosis). This condition has a major impact on my daily life and my experience (outline the symptoms). I’m under the care of (name of the physician) at (name of the medical provider). They explain in the attached Letter of Medical Necessity why this procedure is beneficial. They state (insert a statement from the letter). Consult the letter for more information.

Additionally, I have included supplemental information about the nature of the procedure and its impact on my condition. I hope you will review all the documentation I provided and reconsider the previous decision to allow coverage for (name of the procedure) since it is necessary for my well-being.

If you require more information, please don’t hesitate to get in touch with me directly at (phone number or email address) or my physician at (contact information).

Thank you for your attention to this matter. Any consideration of this appeal is appreciated.

Best regards,

Name and signature

Address

Enclosures:

Everything You Need To Write Your First Formal Letter

While writing any sort of formal letter can be tough, once you see a few examples, it gets significantly easier. Use the pointers we mentioned to get you started and you’ll most likely be done with the first draft in record time.

If you feel uninspired, feel free to use our sample letters, fill in the blanks, and fine-tune them to your particular situation. This is especially helpful if you want to avoid coming off as condescending or brash.

Furthermore, you’ll hit all the key points so you don’t have to worry about missing bits of important information.

Good luck!

What You Need To Know About Choosing An Expert Witness

Mon, 26 Dec 2022 07:36:32 GMT

When preparing to go to trial, attorneys should look at different ways to strengthen their cases. In many situations, hiring an expert witness has many benefits you should consider, especially in the early stages of preparing a case.

For instance, if you’re involved in a case of billing fraud or medical malpractice, an expert witness can bring new information to light and explain complex ideas to the judge and/or jury.

More importantly, they can help you by putting together an expert witness report, which is one of the greatest resources you can leverage in your case.

Here are the basics.

The Role of The Expert

As the name suggests, an expert witness is an individual who has a great depth of knowledge relevant to the matter of the case.

They can serve multiple purposes, most commonly:

1. Determining the value of the case

2. Creating defenses, claims, and counterclaims

3. Assisting with the document review process

4. Writing discovery requests

5. Challenging the expert of the opposing party

6. Evaluating and calculating the damages

7. Assisting the factfinder during testimony

8. Analyzing and responding to claims and theories from the opposing party

While they may handle multiple tasks, experts can be either of a consulting or testifying type. A testifying expert can present evidence on the trial while a consulting one has been consulted before the litigation or trial but doesn’t testify in court.

Naturally, a testifying expert (since they’re a witness) must be disclosed and involved in discovery, while a consulting expert doesn’t need to be disclosed to the other party.

Qualifications of The Expert

Since the qualifications are always challenged, you need to do your homework. The first step is reviewing the expert’s experience and qualifications to determine if they have the necessary expertise in the subject matter relevant to the case.

Most importantly, you also need to make sure that their prior testimony or reports don’t conflict with the case they are currently in consideration for. Additionally, check if they have any prior disqualification or Daubert challenges on their track sheet.

Naturally, if you learn that the expert you want to retain has been disqualified from a previous similar case, you should find someone who’s a better fit.

Expert Witness Report

By leveraging this document, you can provide the court with different details, processes, and evidence of the subject matter.

1. The structure of the report

The way an expert witness report is constructed usually depends on the type of the case, along with how the expert frames their methods while connecting different pieces of evidence. Typically, it will be based on a testimony in the case.

An expert witness report usually consists of several pages and contains a plethora of information. One of the key parts is the disclosure which identifies the names of the defendant and the plaintiff, as well as the relevant dates of the stages of the case and its main issue.

The report will be signed and then given to the judge or the attorney. It has to contain a comprehensive statement that covers the opinion, different processes, and describes the evidence and the incident.

For maximum clarity, an expert witness report should contain visual aids such as diagrams and different exhibits.

Furthermore, the report must contain the expert’s qualifications and their publications. It must also list other cases where the expert presented testimony and the compensation for working on the case at hand.

The meat of the expert witness report contains the expert’s opinion of the case. For instance, they may describe the incident and their opinion on why the issue occurred. In personal injury cases, the witness describes how the negligence of the defendant put the plaintiff in harm's way.

The summary of the facts is usually found at the beginning of the report. It describes everything the expert will testify about or the details they will explain in the courtroom.

This section will also contain any contradictions against the evidence, coupled with any criticism on how the opposing party addressed this evidence. Typically, the reconstruction of the events, along with the visual aid, will also be found at the beginning of this section.

Is the expert witness report shielded from discovery?

Depending on the jurisdiction, the rules may be different. This is generally the case with drafts of the reports. In some jurisdictions, these are shielded from discovery while in others, they need to be made available to the opposing party.

However, even in jurisdictions where the drafts aren’t discoverable, the attorney still must provide the information on communications related to the compensation of the expert, including the data that the attorney provided the expert with. In addition, they must identify the assumptions they provided that the expert will use to form their opinion in the report.

Expert Witness Testimony

Even if they are your witness, an expert witness may be deposed by the opposing counsel. That way, they can question the expert on their qualification, methodology they used in the report, and key assumptions. They may also ask questions about the analyses that the expert rejected and any information that didn’t end up in the report.

In the deposition, the other party can limit the scope of the expert witness’s testimony by learning what they aren’t going to testify about on the trial stand.

In both state and federal courts, the judge will use the Daubert standard to determine if the testimony is scientifically valid and whether proper reasoning was used for the facts of the case.

The Daubert standard answers the following questions:

1. Can the theory or technique be tested?

2. Is the theory based on peer-reviewed research?

3. Does the technique used have a significant error rate?

4. Does the technique or the theory have a maintenance of standards?

5. Has the theory or technique been accepted by the scientific community?

Any statement made during the deposition can be used by the opposing party to impeach the expert at trial.

Your Go-To Experts For Medical Billing

If your client is involved in a case where medical bills are a major factor, you need an expert witness who can clarify all the CPT codes in the plaintiff's medical bills.

We can help your case with a comprehensive expert witness report that covers the analysis of any medical bills, as well as the analysis of the charges and the summary of issues and processes.

Help your client win their suit by letting MBA assist you every step of the journey and demystify any billing errors. Call (800) 292-1919 to schedule an appointment with the experts for medical billing with one of the best track records in the industry.

Common Billing And Coding Mistakes - And How To Avoid Them

Mon, 19 Dec 2022 09:37:05 GMT

Coding and billing mistakes are unpleasant scenarios for all parties involved. For example, patients have to deal with the fact their provider won’t help them resolve the problem. At the same time, for medical facilities, these issues can be destructive as they end up in claim denials.

Since an insurance bill that is chock full of mistakes will be rejected, the claim will take twice as long to get processed. As a result, medical providers have to pull double duty at the expense of actually helping patients.

In other words, insurance billing is the main funding resource of all healthcare providers so billing errors need to be avoided at all costs.

Continue reading this article to learn all you need to know about common billing errors such as bundling and unbundling medical definition, and how to steer clear of them.

Most Common Mistakes

The main cause behind almost all errors in coding and billing is the inattentiveness of the staff. This is good news because it means being familiar with the mistakes can drastically reduce the chances of them happening. Here are the main offenders:

1. Not verifying insurance

This mistake is very expensive to deal with, and surprisingly, very common. Thankfully, it’s easy to circumvent since it usually happens out of pure routine. For instance, a patient may visit your clinic/practice regularly. Because of this, your staff may simply assume the insurance policy of the patient has remained unchanged and they’ll fail to check the terms.

This is easily solved by always verifying the insurance for new, as well as loyal patients.

2. Lack of documentation

According to the Social Security Act, Medicare won’t cover unnecessary services. This means they will only cover the services needed to establish a diagnosis or treat an illness.

Thus, sometimes it’s imperative to supply the medical records that support medical necessity. This documentation could include anything from medical history to discharge summaries. Failure to produce these documents typically ends up being seen as if no service has been provided.

3. Missing claim information

On occasion, staff may accidentally leave fields blank. If any field is empty, the insurance company will deny the claim.

Instruct your staff to double-check all fields to ensure nothing is missing and remind them to attach the required documentation. Even if you’ve switched to electronic claim, set up your software so it doesn’t allow the claim to be submitted until all fields have been filled.

4. Lack of detail

Claims need to be coded to a high level of specificity because insurance companies will reject those that lack specific detail. Every diagnosis or procedure has to meet the maximum number of digits for the particular code.

This often happens with untrained staff members who aren’t aware they are making a mistake while coding.

5. Missed deadlines

Even if you file the claim correctly and refrain from making any other errors, your claim will most likely be rejected if you don’t submit it within the requisite timing window. In some cases, even if you submit the claim before the deadline, it will get denied by the insurer if they receive it late.

Always keep in mind that the period of submission is 12 months. To be on the safe side, send your claims as soon as possible.

6. Typing errors

Precision matters most with coding. But then again, that’s easier said than done as mistakes and typing errors happen all the time. The problem is that the insurers won’t let an incorrect date or a typo in the patient's name slide.

To avoid this slip, always double-check all the data until you’re absolutely sure everything checks out.

7. Not verifying coverage

Insurance information can change at any time, making it necessary to verify coverage for a treatment time whenever you provide a service. Make sure every medical procedure you did is covered by your patient’s insurance, and also check the status of their coverage.

8. Using outdated codes

If the codebook your staff is using is outdated, you may end up with bills using the wrong codes. All the treatment codes, along with the diagnosis and treatment have to match. If they don’t, your claim will get denied.

You and your staff should keep up with the latest changes in medical billing, which is a field that is constantly getting updated with the latest discoveries. For instance, in 2022, many outdated codes for pain management were eliminated and replaced with more detailed ones.

9. Unbundling or bundling medical procedures

These mistakes are quite complex so to understand them better, it’s important to provide an unbundling medical definition. In simple terms, unbundling is a practice of billing multi-step procedures separately instead of billing them as a single procedure.

A minor procedure is sometimes a component of a bigger procedure. For example, when performing a nasal endoscopy, it’s customary to have to cauterize a nosebleed. Even though there is a separate code for the cauterization of nosebleeds, it shouldn’t be used as in this case, the procedure is already a part of the endoscopy.

Unbundling medical definition is also often mentioned when discussing billing fraud. Making this mistake can provide a higher reimbursement rate, which is why it’s also a common form of medical billing fraud .

To stay away from bundling or unbundling, see to it that your coders refer to the relevant coding book to see which procedures they have to bundle.

How to Avoid These Errors?

Making mistakes is easy, which is why it’s imperative to double-check almost everything before filing a claim. That goes for the personal data of the patient, their coverage, the correct codes, etc.

Everyone in your organization should work together to make certain the billing and coding processes are always smooth and mistake-free. Physicians should work together with the support staff to complete the paperwork before filing anything.

As an extra line of defense, you can also leverage the services of a clearinghouse. These companies can check your claim for errors and if they find anything, they will send it back so you can make the appropriate corrections.

A Healthy Revenue System

By decreasing the occurrence of billing and coding errors, you’ll prevent any disruption to your organization’s revenue system. You’ll keep at arm’s length claim denials, loss of revenue, and even criminal liability and expensive federal penalties.

It all starts with a little bit of patience. Now that you know which mistakes may happen, you can take the necessary precautions to keep away from them.

How To Get The Most Out Of A Life Care Plan?

Mon, 12 Dec 2022 09:36:44 GMT

If you’re in the middle of representing a client in a personal injury case , you might be considering whether you should leverage physician life care planning. After all, you have to do everything in your power to deliver the best outcome for the plaintiff, so why not?

There’s a caveat, though. Since these plans can influence the jury, you shouldn’t surrender all control. Life care plans are only as beneficial as their content and you have to ensure you and your client are getting your money’s worth.

To get the most out of physician life care planning, you should first learn a thing or two about it to understand to expose any weaknesses in the life care plan itself.

Let’s get started.

What Is Life Care Planning?

In short, a life care plan is a dynamic document that outlines the plan of current and future medical costs for individuals requiring long-term care. Physician life care planning is the best solution for planning out the lifetime needs of individuals dealing with disabilities and chronic health issues.

It includes the cost of evaluations, diagnostic testing, therapies, and any adaptive equipment, as well as medical care, medication, etc. As such, physician life care planning can be considered an integral part of personal injury cases, workers’ comp, and similar cases as it can clearly demonstrate the full extent of the plaintiff’s ailments and the associated costs.

Generally, this is a diverse profession as life care planners come from a wide variety of medical professions such as nursing, occupational therapy, general practice, and so on.

How To Ensure That The Life Care Plan Checks Out?

If you’ve decided to leverage physician life care planning, the battle is not yet over, so to speak. You still have to make sure that the report and testimony check out before filing anything. You can do so by checking the following things and asking some key questions.

1. Are pre-existing medical conditions included?

Ask the life care planner if the plaintiff had any pre-existing medical conditions and if those costs are included in the report. Pre-existing conditions and the costs for threatening that particular condition should not be included in the life care plan because treatment would have been required even if the injury never occurred.

The only exceptions are some chronic illnesses or prior orthopedic injuries that were aggravated by the injury central to the case.

2. Did any injuries happen at a later date?

Illnesses or injuries that occurred after the event in question should be separate in the report if it’s determined that certain diagnoses or treatments aren’t connected to the injury addressed in the life care plan. In other words, the costs of the later injuries shouldn’t be a part.

3. Were potential complications included?

The treating physician needs to provide their opinion about the certainty of future medical service. For instance, if the physician states that a medical service will be required within a reasonable certainty, the cost of the service in question should be included in the life care plan.

On the other hand, if the physician states it’s possible that a service may be required, then it’s considered a potential complication. Then, it should be listed separately and its cost shouldn’t be included in the life care plan.

4. Is the life expectancy adjusted?

Since the life expectancy of the plaintiff has a direct effect on the costs of future care, it should be addressed in the life care plan. Inquire with the life care planner about their process and how they sourced their data.

This is especially important in cases with catastrophic injuries that may drastically decrease the life expectancy of the plaintiff. Ask them if they had consulted a life expectancy specialist who concurred with the data in the report.

5. Did an interview with the plaintiff take place in person?

You should ask the life care planner if they had visited the plaintiff in their home. This is crucial as the full extent of the disability can only be realized if the interview took place in person. Conducting an in-person interview is a way for the life care planner to gain a better understanding of the impairments, as well as the living situation.

This may help them come to a better understanding of whether the plaintiff will require additional assistance and/or any home modifications.

6. Did the life care planner use the relevant medical records?

An accurate life care plan can only be created by using the most recent medical records. You should always ask a life care planner if they used the latest records. This is because, in some instances, the life care planner may not have been provided with the up-to-date information or the medical records available to attorneys.

7. Were the treating physicians interviewed?

Even though the life care planner may have a medical background, they should still interview the treating physicians. The current physician can explain the person’s current condition and also offer recommendations on future care.

A life care planner should also document any discrepancies between their own recommendation and the recommendation of the treating physicians. If the physician denied the request from the life care planner, that request should also be documented.

8. The sources for costs used by the life care planner

Typically, life care plan standards necessitate the use of usual, customary, and reasonable prices to provide sources for the current cost of services and goods. Some life care planners may use costs from an individual practitioner which may be unreasonable and thus, shouldn’t be included in the life care plan.

9. Generic drugs vs. brand-name drugs

Unless specifically required, the life care planner should include only the cost of the generic version of drugs. Since these usually cost much less than brand-name versions, the lifetime costs can be sizable if the latter is used in the report.

Ask the life care planner which costs they used as failure to correctly average them may result in over-funding or under-funding a plan.

The Devil Is In The Details

Physician life care planning can make all the difference in your client’s quality of life. Thus, you should see to it that the life care plan accurately reflects their needs and provides a precise assessment of the costs.

Since life care plans can be vast and complex, mistakes can happen and overworked life care planners might miss a few things or even deliberately cut corners. To make sure this doesn’t happen to you, always check the things we outlined above before signing off on the report.

That way, you’ll save everyone the trouble of going back and reevaluating a life care plan that may include pages and pages of content.

What Is HCC Coding And Why Is It Important?

Mon, 05 Dec 2022 10:45:07 GMT

While value-based healthcare is one of the fairest healthcare delivery models around, it’s not without its challenges. Yes, it’s designed with the patient in mind, minimizing the costs of healthcare and improving patient outcomes. Still, the cost and utilization in this system may be complex to navigate.

This is because the healthcare providers cannot rely on the sheer volume of delivered services to get paid in the value-based healthcare model. They’re compensated based on the health outcomes of the patients. Another component in the amount of the payment is also the complexity of the patient group for which healthcare services are provided.

In other words, the annual complexity account has a great impact on the value of the payment to providers, which is why it’s imperative to accurately describe the true complexity of patients to the insurance companies.

This can all be accomplished through HCC coding.

HCC Coding Defined

What is HCC coding can be answered by breaking down the acronym. HCC stands for hierarchical condition category and in the basic sense, it’s just a risk-adjustment prediction model.

It was designed to predict risks and estimate the lifetime healthcare costs of the patient by considering different factors, determinants, and conditions that may impact the individual prognosis of the patient over a longer period.

Because the healthcare industry is slowly shifting towards value-based models, the use of HCC coding is also becoming more and more prevalent. The coefficient of HCC changes depending on the category of the patient. The patients are assigned risk scores by connecting the set of HCC codes to different demographic factors.

An extra layer of complexity in the whole question of what is HCC coding is the fact that it also allows for assigning a risk adjustment factor (RAF) score to patients. Risk-adjusted payments, in simple terms, mean that the payer pays more for unhealthy patients and less for healthy patients. This ensures that the insurance company is unable to profit by dropping unhealthy patients.

Thus, a patient with multiple chronic ailments will have higher long-term costs, while ones with not as many health conditions will have lower average expenses.

HCC codes are based on ICD-10-CM codes and are supplied by providers to Medicare or health plans.

The ICD-10 codes correlate to medical diagnosis and there are over 10.000 of them. Each reflects specifics of a different medical condition. While HCCs are similar to ICD-10 codes, not every code is tied to an HCC.

Why Is It Important?

Now that you know what is HCC coding, it’s time to explain its importance. HCC coding is a great way to paint a full picture of not only the long-term complexity of treatment but also the entire health of the patient.

For instance, providers are encouraged to examine the patient record and discover any societal health determinants in order to predict outcomes that may change the value of the provided care.

The RAF score also plays a part in determining the cost metrics and risk-adjusted qualities as they account for the differences in the complexity, cost performance, and quality of an individual patient. Additionally, demographic information and conditions documented in the patient encounter are also tracked in the RAF score.

The payments to providers are based on the anticipation of risk of patients with chronic health ailments and are calculated from specified ICD-10 codes. Failure to accurately describe and note the full extent of the patient's condition through proper coding means risking a substantial loss of revenue.

Processing HCC Coding

ICD-10 codes require additional detail regarding the individual care of a patient and their medical conditions. This also applies to chronic conditions and their management such as alcohol dependence or artificial openings. Both examples may predict future healthcare needs. They also apply to HCCs and may accurately predict the future well-being of the patient.

Risk factors such as the previous two are taken into account when determining the pay scale of the patient. The more of these conditions that a patient suffers from, the risk to their health is higher. Patients who are less healthy than average have an HCC score higher than 1000, while the healthier ones have a score that’s under 1000.

Yet, mistakes can happen and providers often miss the opportunity to specify HCC in different scenarios, which leads to risk scores that aren’t painting the full picture.

How to Make HCC Coding a Success

Most problems arise from providers who assign codes directly at the end of each patient encounter without the necessary knowledge of ICD-10 codes. For example, providers may not be fully familiar with all the coding guidelines, encoders, or coding resources.

It’s also worth mentioning the coders themselves, as their experience and credentials have a big effect on outcomes. This is because success with HCC coding requires expertise in ICD-10 codes.

Furthermore, the successful processing of HCC coding and documentation is important for financial integrity, maintaining compliance, and accurate quality measures. As such, organizations should take extra care when evaluating outpatient documentation. They should also proactively find areas where they could actively improve coding quality regarding HCCs.

While coder and provider experience and insight matter, many organizations are seeing good results by introducing technology into the process.

Tech may improve the capture of documentation, and it’s also possible to partially automate coding with computer-assisted coding solutions. The same applies to simplifying clarification and follow-up encounters with digital clinical documentation software.

Medical Coding Matters

In the days before risk adjustment factors were common, reimbursement hinged solely on demographic factors. Nowadays, organizations can rely on HCC coding which is at the core of revenue management. It’s true that demographics still influence the risk scores, but now they’re calculated equally and consistently.

HCC coding also presents unique opportunities for providers to start with efficient approvals and reimbursements - things that play a major role in the profitability of the medical practice.

However, knowing what is HCC coding is just the beginning of an organization-wide effort to improve. Since it plays such an important role in the revenue cycle of a healthcare organization, you should take extra care with your HCC coding efforts.

This means you have to make sure that your coding is accurate, efficient, and secure as this is the only way to achieve compliance and a healthy stream of revenue.

TPN Medical Abbreviation Explained

Mon, 14 Nov 2022 08:09:14 GMT

If you or your family member were diagnosed with a serious DI tract disorder, you’re probably trying to learn more about the condition challenges of living with that condition. Maybe you ran across the TPN medical abbreviation in an online article, or your doctor recommended it, and you want to know what you should expect.

We can’t blame you, as these terms can sometimes be quite confusing.

Thankfully, you’ve come to the right place as we’re going to go deeper into the TPN medical abbreviation and explain exactly what TPN is, and how it can help you or a loved one.

TPN Medical Abbreviation Explained

TPN stands for Total Parenteral Nutrition but you may also hear it referred to as intravenous/IV nutrition feeding. It’s a method of supplying nutrients to the patient’s body through their veins. This is especially important for patients who cannot get nutrition normally.

For instance, people who have GI tract disorders that require complete bowel rest and even those who do not have a functioning digestive tract.

TPN is effective at providing individuals with these ailments with all the calories and micronutrients they need to stay healthy. It consists of a solution that contains a mix of protein, carbs, glucose, and minerals i.e. everything the body needs.

TPN is commonly administered through vascular access devices such as:

1. Peripherally inserted central catheter (PICC) lines

2. Peripheral Intravenous lines

3. Central lines (Hickman or Groshong catheters)

4. Midlines

What Type of Patients Use TPN

TPN is very versatile and can be administered at home or the hospital making it useful for a lot of people. Most commonly it’s administered to patients that have some of the following diseases:

1. Crohn’s disease

2. Cancer

3. Ischemic bowel disease

4. Short bowel syndrome

5. Severe cases of pancreatitis

6. Intractable vomiting

7. Diarrhea

8. High-output fistula

TPN is also used on critically ill patients that are unable to receive oral nutrition.

While it’s a great method of supplying nutrients to patients with severe GI problems, it’s not recommended to be used constantly on patients who have an intact digestive tract. This is because it might cause additional complications if used routinely. It also doesn’t preserve the function and structure of the digestive tract, and it’s more expensive than normal food.

TPN is a typical way to nurture children and teenagers. For example, children with short bowel syndrome that occurs due to diseases like microvillus inclusion and other intestinal diseases are often on TPN while awaiting an intestinal transplant.

Why is TPN So Effective?

Parenteral nutrition can be either total or partial. While the partial version supplies a fraction of daily nutritional needs and is used to supplement oral intake of food, the total one gives patients all daily requirements regarding nutrition.

In more detail, TPN medical abbreviation for total nutrition requires a mixture between 30 or 40 mL of water, 30 or 45 kcal of energy, and between 1 and 2 kilograms of essential fatty acids, as well as additional vitamins and minerals.

This is not a rule, as these solutions will always be fine-tuned to meet the individual needs of the patient. The mixture will depend on the function of the organs, the condition, and the age of the patient.

For instance, patients with respiratory failure will require a mixture that’s mostly liquid and provides nonprotein calories, while those with kidney diseases can benefit from a limited volume of water.

How is TPN Administered?

TPN is administered by placing a catheter or a needle into the large vein going directly to the heart. This is called a central venous catheter, and since it needs to be kept stable to avoid any complications, TPN is administered in a sterile environment.

This means that the tubing will have to be changed every day. The same goes for any dressings.

The process occurs for 10 to 12 hours per day and multiple times per week. This is why it’s common to administer the infusion during the night so that the patient doesn’t have to go through it during the day.

Since the risk of infection is high while administering TPN, for home administration, patients need access to a nurse who can recognize the various signs of infection.

The nurse should also be familiar with the correct process of administering TPN.

For instance, the correct method of administering starts with the proper storage of the liquid. Each dose has to be removed from the fridge five minutes before it gets used.

The Risks and The Benefits of TPN

The biggest benefit is the nutrients this infusion provides that are essential for hydration and maintaining the energy levels of the patients. With TPN, patients can feel better and heal more quickly. This is especially important for teenagers and children as they’re still in their development process, and without proper nutrients, they may experience growth delays.

However, TPN is not without its risks.

Typically, the biggest concern is catheter infection which may result in sepsis. Additionally, doctors usually need to look out for blood clots that may form when the line moves. Long-term use of this infusion has also been connected to bone and liver disease, so it’s essential to have a physician monitoring the patient for any complications.

Also, glucose abnormalities can happen as a result of TPN usage, and medical professionals have to keep track of their patient’s glucose levels and fine-tune the contents of the TPN to get rid of any insulin imbalances.

Another common complication is liver dysfunction which can occur from excess amino acids which can cause increased alkaline phosphatase hyper-ammonia. There are also cases of hyper-ammonia and painful hepatomegaly, serious hepatic complications which can lead to twitching and seizures.

Additional complications include gallbladder problems, metabolic bone disease, etc.

TPN Keeps You Strong

TPN medical abbreviation is something you should remember, because aside from all the possible complications, it’s still one of the best ways to deliver nutrients for patients with GI tract ailments.

Why? It’s useful and it’s relatively safe as most of the complications we mentioned can be avoided through proper administration and close monitoring.

Hopefully, this important method of nutritional support doesn’t seem as scary or as complex as the first time you saw the TPN medical abbreviation.

The Role Of A Medical Expert In A Trial

Mon, 07 Nov 2022 09:01:38 GMT

If you’re a part of a legal case, our guess is that you are probably feeling a little bit lost and are in need of guidance. Typically, that guidance comes in the form of an attorney.

Still, attorneys don’t possess all the knowledge in the world so depending on the circumstances, your legal counsel may look for external consultants for help - most likely the expertise of a medical expert.

Today, we’ll describe the occupation of these expert witnesses and explore how they can benefit your case.

Who Are Medical Expert Witnesses And What Do They Do?

In cases such as medical malpractice , a medical expert witness is a crucial asset for plaintiffs filing a lawsuit against another party. For example, if you file a lawsuit against a negligent physician following an injury, the testimony by an expert can do wonders for strengthening your case.

These experts come from a variety of different medical backgrounds. For instance, a medical expert witness may be a nurse, physician, surgeon, or any other licensed medical practitioner. These witnesses have the necessary skill, educational background, and experience which qualifies them to testify on behalf of the plaintiff on a particular medical area in a court of law.

Oftentimes they are hired by attorneys in different kinds of cases, most commonly in malpractice and personal injury lawsuits during discovery and trial stages.

Their role is pretty simple. Since medical cases require a high degree of advanced skills, the court requires someone with the necessary knowledge to clarify the facts of the case. The main purpose of their testimony is to educate the jury and the judge on the intricacies of the injuries that the plaintiff has experienced.

For example, they may be called upon to testify on the issues related to their area of expertise such as the standards of care. They may also testify as to the severity of the injury in question, and how the injury has affected the plaintiff and their day-to-day abilities.

This is where their ability to explain and present complex information into layman's terms comes in. A medical expert witness is usually the witness that may very well change the course of a personal injury or a malpractice lawsuit.

Even though they’re mostly associated with providing testimony at a trial, they can also provide value for attorneys in all stages of litigation. For instance, they may assist attorneys in evaluating cases before filing a lawsuit, but they’re as valuable as the case progresses to further stages such as discovery.

Now, whether you need a medical expert witness depends on the complexity of the case and the potential settlements. In lawsuits where the final settlement is relatively low, the cost of hiring a medical expert may outweigh the benefits.

Nevertheless, the higher the value of the settlement the greater the need for a compelling expert medical testimony.

The Benefits Of Expert Witness Testimony

If the case you’re involved in fits the bill, here are the benefits of working closely with a medical expert witness:

First, you can strengthen your case and make your points more persuasive. This is what ensures the success of your lawsuit, as cases that lack credibility generally yield low settlement offers or result in a straight-out dismissal.

With an expert on board, you can see to it that your case gets presented in a logical manner and that you have enough solid evidence to back up your claims.

Equally as important, a medical expert witness can testify on your behalf and inform the jury of any information that’s unknown to the uninitiated. In malpractice cases, the expert can do their magic and explain the facts of the case to influence the jury. Since juries usually have limited knowledge about medical issues, they’ll have no clear idea about the procedure or the injury in question. An expert can help guide the jury through the intricacies of the event in great detail that will clarify if any mistakes have been made.

For example, they’ll point out exactly what went wrong in the procedure, how it could have been avoided, and why they consider the case to be medical malpractice.

Important Medical Expert Witness Qualities

It goes without saying that the medical expert witness you hire needs to be Board Certified and possess experience in areas relevant to your case. You should seek out an authoritative physician who is still active in their field but consults only part-time. This way, they don’t sacrifice their credibility or abandon their medical practice to participate in medical legal cases.

When hiring a medical expert witness, make sure that they have demonstrated experience in the specific conditions or procedures that apply to your case.

Additionally, an expert has to have the necessary experience with medico-legal processes which includes knowledge of standards of care and causation. They also need to have a deep record of written and oral testimonies.

Lastly, an expert witness needs to possess the communication skills necessary to demystify complex medical terms and procedures to jurors. They have to be able to condense their expertise into a clear and concise testimony without relying on medical jargon.

Get Your Point Across

Hiring an expert witness in your medical case can make the difference between disappointment and getting compensated fairly. Without them, jurors and the judge wouldn’t have the necessary insight into the intricacies of your malpractice or personal injury case .

Any legal process has one goal - reaching a reasonable settlement.

A medical expert witness is there to ensure that this process happens faster instead of the case ending up in years of complex litigation that won’t go anywhere. As a huge plus, sometimes, the other party will settle the case out of court when they learn that you’re bringing on an expert who will testify on your behalf.

The opposing party may even hire their own expert witness. This will only help the case as the jury will get to hear two opposing testimonies regarding a procedure that may have gone wrong. Ultimately, this only helps the jury reach a conclusion that is correct.

All in the name of justice, we say!

The Career Of A Life Care Planner

Mon, 31 Oct 2022 08:48:25 GMT

Not all medical professionals work directly on treating a patient’s injury or illness. Some ensure that the future of debilitated individuals is of the highest quality possible.

How?

With life care planning .

Certain injuries or illnesses may leave a person in need of lifelong medical care. These individuals require the help of a medical professional such as a life care planner to produce a comprehensive healthcare plan that outlines the needs and cost of their treatment.

Here’s what a life care planner does, what their credentials are, and what kind of training is required to become one.

What Is Life Care Planning?

Thankfully, most people need short-term medical attention, but there are some who require long-term medical care due to different kinds of crippling issues. This includes catastrophic injuries like spinal cord injuries and traumatic brain injuries, as well as debilitating illnesses such as paralysis, diabetes, or mental health disorders.

The long-term needs of such individuals are outlined in the life care plan, which is a dynamic document based on standards of practice, assessment, research, and data analysis. It provides a concise framework for current and future medical needs and the associated medical costs for individuals suffering from chronic health issues or having lasting effects from injuries.

The professional performing this task is a life care planner whose task is to evaluate individuals with chronic health concerns and outline the needs created by the disability. They research everything from items and services that the patient needs to their current and future medical costs.

All of these aspects require a certified professional who possesses the knowledge of the nuances of healthcare requirements and the ability to anticipate any progressions of the medical issues at hand.

This is a completely different game than coordinating and planning short-term care as a life care planner may be responsible for creating a care plan that covers a few months, years, or in extreme cases, the rest of the patient’s life.

The life care plan in question is based on different factors such as the severity of the injury or the illness, along with the wishes, abilities, and needs of the patient and their family.

Since every situation is different and the effects of medical ailments are never the same, life care plans are never identical and are often completely custom.

The Role Of The Life Care Planner

This job is nuanced and dynamic, so these professionals need to possess the necessary interpersonal skills to properly communicate with both the patient and the family about their requirements.

Since their role dictates that they have to create a safe and comfortable plan for the patient, the life care planner has to be familiar with the treatment for different ailments in combination with the abilities of the patient. This usually requires a high level of decision-making skills as life care plans might sometimes require adjustments.

A life care planner may start by assessing the patient and their diagnoses, which helps inform what type of care they’ll require in the future. As such, this job entails studying medical records and interviewing physicians, patients, and their family members.

This all helps determine the proper care of the patient and what they can do financially and physically.

Because the life care plan has to meet the needs for long-term care, it should contain the types of treatments the patient will go through, the physicians who will provide medical care, as well as the financial details of the medical care.

Medical care in the US is expensive, hence, it stands to reason a patient or their family might not be able to finance it. This is why life care planners are so important, as they work directly with government agencies and insurance companies to help pay for long-term medical treatment. They might advocate for their disabled patients in these situations to get the necessary funds for care.

The Research Process

A life care planner has a lot of responsibilities, but the main one is completing a diligent research process. Not only do they consult doctors, but they may also research different treatment options such as experimental and alternative medicine if a particular patient is open to unconventional medicine.

However, this is not to say that life care planning only includes consultations. The foundation of these plans comes from different sources such as case management, medical, rehabilitation, and psychological sources derived from clinical research, records, and medical literature.

Thus, a person creating the life care plan scours through a myriad of disability and medical journals to establish a medical foundation for the treatment. They may:

1. Draw a direct link between the recommendations in the plan and medical records.

2. Consult with different medical professionals to answer questions not present in the existing medical records.

3. Consult specialists

4. Employ clinical practice guidelines

To institute a rehabilitation foundation, the process is pretty much the same with the addition of using supplementary research literature. The same applies to case management and establishing a psychological foundation which might include communication with the case manager.

Life Care Planning Education

These professionals come from different medical and rehabilitation backgrounds. For example, nurses, occupational therapists, counselors, physical therapists, social workers, psychologists, and physicians.

Since this is a transdisciplinary practice performed by different professionals, the undergraduate or graduate training programs are specific to each discipline. Nevertheless, some programs provide training aimed specifically at life care planning.

Postgraduate programs are easy to find - the University of Florida offers a life care planning certificate.

Employment Prospects

Life care plans are used in litigation and leveraged by case managers, trust officers, discharge planners, as well as families. Because the use cases are quite plentiful, many people are drawn to this calling. While it’s impossible to determine the exact number of professionals in this field, the number is constantly increasing.

Life care planners may work for different types of companies such as insurance companies and their salaries depend on their companies. However, independent planners charge an hourly rate that depends on the professional reputation, location, and quality of work itself.

Life care planners often earn a higher salary than the national average at around $75k per year on average.

A Noble Calling

By getting into this field, you can help disabled or ill individuals and their families get peace of mind and make sure that their loved one is taken care of. It’s a noble and fulfilling profession for those that want to make a difference in other people’s lives.

Bear in mind that putting together life care plans does take a lot of work and patience. You also have to be emotionally prepared to work firsthand with grief-stricken families and individuals with varying levels of disability or ailment.

It’s also important to note that your success in the field depends on not only your knowledge but your communication skills. Additionally, you have to be a master at networking since life care planners usually need to build a lot of relationships if they’re to have a steady stream of clients.

The Role of a Vocational Expert in the Divorce Process

Mon, 24 Oct 2022 07:39:51 GMT

Divorce can be very tough. Not only are you parting with your significant other and processing some heavy emotions, but the question of alimony will inevitably come up.

No two divorce proceedings are the same, yet, those that go down smoothly are a rare sight.

To ensure everyone plays by the rules and that the judge’s decision is fair for both parties, vocational evaluation divorce often comes into play.

No matter which side you’re on, you can still benefit from a vocational evaluation divorce expert. Here’s a breakdown of their role in a divorce hearing and how hiring your own can benefit you.

Vocational evaluation explained

If you’re wondering why vocational evaluation divorce is so important, you only need to look at the background of these professionals. Vocational experts have the education and knowledge to accurately assess the ability of a person to work. This includes the qualifications, skills, and current employment opportunities in the area.

An integral part of the vocational evaluation divorce is also concluding if additional education or training might improve one of the spouse's abilities to find employment.

Since earning capacity of the parties is a key factor in determining the amount of alimony or child support, vocational experts are an essential part of the process.

The procedure employed in the vocational evaluation divorce is not simple as the expert will conduct an in-depth analysis to determine the true earning capacity of the spouse. For instance, they will take a look at the individual’s age, education and work experience, relevant job history, physical and mental health and capabilities, as well as vocational interests.

These factors help form a clear vocational picture of the spouse as they may limit or increase their chances of finding employment. Lastly, a vocational expert will examine the current job market.

All of this information might be requested by the court, yourself, or the opposing party.

Unique challenges of divorce proceedings

This is an emotional period for everyone involved. When you combine high stakes with a general misunderstanding of the legal system, the results are nothing short of full-on drama. Both spouses sometimes let their resentment boil to the surface and try to force those feelings into the case itself.

In the end, what you may end up with is an unrealistic portrayal of the previous relationship, where too much time is wasted on insignificant things. In some instances, earning capacity, which is important, might get lost in all the commotion.

On top of that, one of the spouses might request alimony that is outside of the realistic possibilities of the other party. Even worse, an educated spouse with a lot of work experience may avoid finding employment.

We’ve also witnessed a spouse choosing to remain underemployed to minimize the alimony.

To prevent these manipulations from materializing completely, any of the parties can request a vocational evaluation divorce. Even though the judge may not follow the opinion of the vocational expert, their testimony and recommendations are one of the best ways to cut through the noise.

Why you should hire a vocational expert

If you’re going through a divorce, here’s how hiring a vocational expert can help you:

To ensure settlements are fairly calculated

An expert’s opinion is crucial to make sure that settlements aren’t dictated by assumptions from the spouses but rather come from solid evidence.

For instance, a husband may claim that his wife is capable of earning a hefty income just because she has a degree. In reality, this might not present the full story as the wife may have been out of the workforce for over a decade as she was taking care of the children.

With a vocational evaluation divorce, it’s possible to bring this fact to the forefront and make certain the alimony amount is fair for the parties involved.

As a bonus, the spouse who’s been unemployed can also benefit from knowing about their actual earning potential when they re-enter the job market. For instance, maybe a degree that meant something 15 years ago doesn’t have many job opportunities today, so the spouse can find out if they need any additional training to become more relevant when job scouting.

To obtain an overview of the spouse’s real earning potential

It’s not uncommon to see a spouse with a higher income attempt to bring down any alimony obligations by claiming they have a lower income. For example, a business owner might claim that the economy isn’t very good and they don’t earn as much as they used to. Alternatively, they may take a lower-paying job during the divorce to achieve the same results.

With a vocational evaluation divorce, you can ensure that strategies like this don’t take any footing in the court of law. Even if the higher-earning spouse isn’t being devious to avoid paying, a vocational assessment can provide the judge with more information on the future earning prospects of the spouse and when they will rebound from the economic perils they’re going through.

To provide a second opinion to the court

If the court orders a vocational evaluation or your spouse requests it, your projected earning potential will usually play a part in the alimony you are going to receive or be required to pay. Let’s say that you are a lower-earning spouse. The alimony that your ex-partner will be required to pay will be reduced by the amount projected in the evaluation.

For instance, if you have the necessary qualifications to earn $60k a year but you’re working a lower-paying job, the alimony payment will be based on your projected income rather than the actual income.

Since the opinion of the vocational expert only plays a part in the final settlement, you may also hire a vocational expert on your own to perform another vocational evaluation and offer a second opinion to the court.

Making the most out of vocational evaluation divorce

A vocational expert's services aren’t limited only to lower-earning spouses as the ones who make more money can benefit from an expert opinion, especially as the lower-earning spouse might try to receive the highest alimony possible.

If you don’t agree with what’s being presented in court, another opinion might be necessary to present all evidence so the judge can make the fairest decision.

Whatever the circumstances may be, having an expert in your corner can never hurt as your future financial situation depends on it.

CPT Codes For Pain Management Procedures

Mon, 17 Oct 2022 13:47:54 GMT

Billing and coding have always been complex, and because new changes are constantly getting introduced, they are only becoming more of a challenge.

For example, millions of people are suffering from chronic pain with the solution being pain management. However, this means that there are new pain management medical billing guidelines medical professionals should be aware of.

Today, we’re going to describe the latest changes in pain management medical billing guidelines, and also address the CPT codes for some of the most common pain management methods.

What’s New in 2022?

For starters, let’s take a look at which codes were eliminated and replaced with more detailed ones. We can officially say goodbye to:

01935: Anesthesia for the transcutaneous image-guided diagnostic surgeries performed on the spinal cord or the spine.

01936: Anesthesia for the transcutaneous image-guided therapeutic surgeries performed on the spinal cord or the spine.

The new codes provide more granularity and identify the type of procedure for which the anesthesia is being used, as well as clarify the location of the procedure.

These are the new codes:

01937: Anesthesia for transcutaneous image-guided procedures such as injection, drainage, or aspiration to the thoracic spine or the spinal cord.

01938: Anesthesia for transcutaneous image-guided procedures such as injection, drainage, or aspiration to the sacral or lumbar spine or spinal cord.

01939: Thoracic or cervical anesthesia for transcutaneous destructive image-guided treatments of the spinal cord or spine.

01940: Sacral or lumbar anesthesia for transcutaneous destructive image-guided treatments of the spinal cord or spine.

01941: Thoracic or cervical anesthesia for transcutaneous image-guided neuromodulation or intravertebral surgeries on the spinal cord or spine.

01942: Anesthesia for intraverbal and sacral transcutaneous image-guided neuromodulation or intravertebral surgeries.

64628: Thermal destruction of the first two vertebral bodies, lumbar or sacral, or intraosseous basivertebral nerve including imaging guidance.

64629: Thermal destruction under imaging guidance on the intraosseous basivertebral nerve. This code should be used for each additional sacral or vertebral body treated after the first session.

93319: 3D echocardiographic imaging and post-processing during transesophageal echocardiography or transthoracic echocardiography for congenital cardiac anomalies for the evaluation of cardiac structure(s), including cardiac chambers and valves, the left atrial appendage, the interatrial septum, and the interventricular septum, when carried out (list separately in addition to code for echocardiographic imaging)

Pain Management Medical Billing Guidelines and CPT Codes

Managing chronic pain has always been a goal for medical professionals, and thankfully, Medicare now covers new pain management treatments such as acupuncture. Let’s see which codes are used most frequently for different methods of pain management.

1. Dry needling

Dry needling is an effective method for treating musculoskeletal ailments in which a certified physical therapist uses a thin monofilament needle to target muscular trigger points. Doing so treats musculoskeletal pain or mitigates any movement impairments.

In contrast to acupuncture, an Eastern medicine method, dry needling was developed through western medicine’s understanding of posture, evaluation of pain patterns, movement function and impairments, and orthopedic tests.

As such, it has the corresponding CPT codes:

20550: tendon sheath injections

20551: injection to the tendon’s origin or insertion

20560: needle insertions to one or two muscles not including injections

20561: needle insertions to at least three muscles not including injections

According to the current pain management medical billing guidelines, trigger point injections (20552/20553) cannot be recorded with the procedures performed on the same muscle group with the codes 20560 and 2056.

2. Acupuncture

A mainstay in Chinese medicine, acupuncture involves inserting thin needles into the skin at strategic points in your body. It’s most commonly performed as a way to treat pain or manage stress. According to traditional practitioners, along with relieving pain, acupuncture restores the energy of the body and activates its natural healing mechanisms.

It’s usually performed to relieve discomfort for multiple conditions such as dental pain, neck pain, osteoarthritis, tennis elbow, and many more.

Regarding chronic lower back pain, Medicare now covers acupuncture as a pain management treatment for up to 12 sessions over 90 days. The CPT codes used for acupuncture are the following:

97810: Acupuncture performed with needles without electrical stimulation. Used for the initial 15 minutes of one-to-one contact with the patient

97811: Covers re-insertions and additional 15 minutes of contact with the patient.

97813: Acupuncture performed with needles and electrical stimulation. Used for the initial 15 minutes of one-to-one contact with the patient.

97814: Covers re-insertions and additional 15 minutes of contact with the patient.

Data for coding acupuncture procedures are not based on the intensity but rather on 15-minute increments of contact with the patients. The latest pain management medical billing guidelines clearly state when each code should be used.

When there is no electrical stimulation during the 15-minute increment, the appropriate codes are 97810 or 97811. If any electrical stimulation is used on the needles, the codes 97813 or 97814 are more appropriate.

Keep in mind that you should only use one code per 15-minute increment with codes 97810 or 97813 being appropriate for the first interval. You can also only report one initial code each day.

3. Radiofrequency ablation

By delivering an electric current to an area of the body, it’s possible to prevent pain signals from traveling through a region of nerve tissue. This treatment is called radiofrequency ablation (RFA) and it can ease chronic pain and discomfort in the lower back area, neck, and arthritic joints.

RFA can be performed under mild sedation in which the patient is kept conscious and can describe the feelings during the stimulation of the nerve.

The pain management medical billing guidelines codes for RFA are:

64625: Image-guided RFA for the sacroiliac joint

64999: Unlisted nervous system procedure

For nerve ablation with conventional or cooled radiofrequency of 80 degrees Celsius, you should use the code 64625. To report pulsed RFA, use the code 64999.

4. Using modifiers

Wrong modifiers usually result in denied claims, so it’s important to brush up on pain management medical billing guidelines and modifiers such as:

Modifier 50: Use for reporting bilateral procedures

Modifier 52: Use for reporting incomplete procedures, for instance - postponing a part of the procedure

Modifier 53: Use for reporting incomplete procedures, postponed for the patient’s safety

Modifier 59: Use to signify the distinction of the procedure from other services performed on the same day

The Evolution of CPT Codes

With so many useful methods of treating chronic pain finally being part of Medicare, it’s natural that we would get new codes for reporting the same procedures. However, the evolution of new CPT codes isn’t limited only to new methods of treatment.

The new codes getting introduced is a great way to avoid any confusion and to supply more detailed information that ensures medical billing is on point. It makes certain that, as a physician, you are paid adequately for the medical service you provided.

If you have any medical bills that need to get reviewed, MBA should be your go-to option.

Additionally, if you have any questions regarding the new pain management medical billing guidelines or CPT codes, feel free to fill out our contact form and we’ll help clear up any confusion regarding any type of medical bill.

Most Common Questions About Vocational Evaluation

Mon, 10 Oct 2022 14:15:23 GMT

A vocational evaluation is an integral part of different kinds of cases, from divorce proceedings to filing for workers' compensation. It also plays a major part in disability claims as the judge decides who gets disability benefits with the help of a vocational expert.

While clients can usually benefit from going through the vocational evaluation, many are skeptical about the whole process.

To dispel any confusion and put your mind at ease, here are some frequently asked questions about vocational evaluation.

1. What is vocational evaluation?

It’s a process in which a trained expert gathers information about an individual regarding their skills, potential, abilities, and limitations in the workplace. This process might include reviewing past employment records, conducting a comprehensive interview, and performing vocational tests that check the abilities and skills necessary to perform workplace tasks.

2. What is the purpose of this evaluation?

The purpose here is to assess the employability and earning capacity of a person to present in front of the court. It might include a vocational report that clarifies details of how that person will return to the job market and details such as:

1. Necessary training time

2. Appropriate programs

3. Ceiling to earning upon completion of the training

4. Job availability

3. Who may request an evaluation?

The question isn’t as clear-cut as it depends on the case and the circumstances.

For example, in divorce cases, a vocational evaluation might be required if one of the parties is unemployed or even underemployed. They might claim they are unable to increase their income. To illustrate, a spouse with specialized training and work experience might allege they cannot find unemployment. To objectively examine their claims, the court may order an evaluation of their true earning potential.

Additionally, one of the parties might also file a motion requesting the court to order the other party to go through this evaluation.

In workers’ comp cases, the insurance company might require the injured worker to go through this evaluation to determine if they are ready to return to work to a full or limited capacity.

4. What are the qualifications of the expert performing the evaluation?

Vocational experts have extensive knowledge of lost earnings, earning capacity, and the cost of replacement labor. In serious personal injury cases, they might determine which jobs are available to the person with the same physical limitations and any possible limitations in the future caused by the injury.

This position requires a master's degree and at least three years of experience that includes necessary recommendations from their supervisors.

Vocational experts also must complete a written examination that covers different competency areas of career counseling.

5. Are there limitations to this evaluation?

This evaluation isn’t a method of diagnosing or treating any psychological issues. If not a part of the referral, it doesn’t allow for counseling over a period of time. This means that it doesn’t cover job placement or development.

An individual cannot fail this evaluation as it’s only a method of identifying the person’s strengths, work capacity, interests and personality, and transferable skills.

6. Is it possible to prepare for the vocational evaluation?

Most clients usually ask this question, but since it’s not ‘’scored’’ per se and you cannot fail or pass, you don’t need to study.

However, there are some things you should have on hand when going through the evaluation. For example, we recommend you bring your resume. If you don’t have one, make sure you can remember your work history and educational background in detail.

If you are going through a training program, it’s helpful to have information that covers things such as the description of the program, how long and comprehensive it is, as well as how much it costs.

If you’re in the process of finding employment, you should bring a detailed record of your job-hunting efforts.

You should also bring any medical records and reports.

Don’t lie or try to manipulate the information in your favor. If you have a lawyer, they’ll prepare you and tell you if there is any information you shouldn’t disclose.

Extra tip: Be nice, as your behavior and attitude will be noted in the evaluation report.

7. What are your rights?

As a citizen of the United States, you have the right to an impartial evaluation. You should also be able to review any test results. You may also disagree with the conclusions of the examiner, and if you do, have the right to take the report to a different vocational expert.

Do keep in mind that this evaluation is not confidential and everything you say may be used in forming the conclusions in the report.

8. What does the evaluation look like?

Here’s the entire vocational evaluation broken down into smaller steps so you know what to expect:

A diagnostic interview

In this interview, the evaluator will gather information about your employability. You’ll be able to ask any questions about the process as well. You may be asked questions about matters such as:

1. Work experience

2. Age

3. Health

4. Absence from the workforce

5. Education

6. Goals and priorities

7. Motivations

8. Personal matters

Vocational testing

10. These tests are performed to develop a work trait profile. In other words, the evaluator will try to assess your employability. You 11. may be tested on your:

1. Ability

2. Personality/Interests

3. Work values

4. Skills

Labor market research

The counselor will try to generate information about your vocational outlook, potential earnings, and training requirements for job positions in your geographical area. You’ll be able to review this information when you receive the report.

Integration of the information

Next, the vocational counselor will combine the information disclosed in the process. This might include your self-report, the counselor’s observations, as well as any medical or psychological report and data gathered in the test.

Recommendations

According to your long-term career goals, the evaluator will recommend the steps you should take based on your interests and your employment abilities.

A vocational evaluation can be a learning experience

Regardless of which side of the curtain you’re on, vocational evaluation is very important. Even if it’s a part of a divorce case, it’s very beneficial for both parties as it ensures fair spousal support, which eventually might translate into a better life quality for both spouses.

Whatever it may be, a vocational evaluation is an opportunity to learn more about your marketable skills and how you can find better employment.

Who knows? You might even discover a new career that perfectly fits your abilities, skills, and interests.

Vocational Expert And Their Role In A Disability Hearing

Mon, 03 Oct 2022 13:58:50 GMT

Disability hearings are a big deal. Before granting you your benefits, the Social Security Administration (SSA) will often require testimony from a vocational expert.

These experts are highly qualified to speak about even the most complex details of the labor market. They’re also required to calculate the exact impact that a personal injury had on the earning capacity of an individual, as well as the skill level required for certain jobs.

Since this expert is the one who brings the relevant knowledge to the table, they are the ones who determine which jobs you can successfully do with the impairments you have. In other words, they’re the experts that determine whether your claim is approved or not.

How Important Is a Vocational Expert’s Testimony?

On the day of your disability hearing, an administrative law judge will call upon a vocational expert to determine if your medical condition is preventing you from working. While these judges have a deep knowledge of laws and regulations regarding disabilities, they’re not familiar with the types of jobs the claimant can do.

The case is decided, so to speak, on the facts of whether there are any jobs you can do. Thus, a judge will inquire about the labor market and the skills necessary to perform certain jobs.

Granted, the judge still has the last word regarding if you will receive your benefits, but not without the input of the vocational expert. After all, it is they who are familiar with the residual functional capacity and its impact on your ability to perform work-related tasks.

In some cases, the judge might be familiar with the limitations in a general sense, but SSA still requires them to consult an expert before they reach their decision. This is because vocational experts are familiar with all the relevant job duties and employment data, so their opinion can pretty much be what determines the outcome of your claim.

Assessment of Your Work History

One of the main roles of the vocational expert is to assess your entire work history to ascertain the exertion and skill level necessary to perform the jobs.

The levels of exertion are divided into four categories:

Sedentary job: a seated job that includes occasional walking or standing and requires lifting about ten pounds.

Light job: involve a significant amount of movement but doesn’t require carrying more than ten pounds and lifting less than 20 pounds.

Medium job: requires a worker to stand or walk for extended periods (at least 6 hours), lifting upwards of 50 pounds, and carrying as much as 25 pounds.

Heavy job: requires all exertion levels.

Skill levels are divided into three categories:

Unskilled job: requires a minimal level of judgment and can be learned quickly.

Semi-skilled job: requires some skill and attention to detail and may require the ability to move hands and feet to complete repetitive tasks.

Skilled job: requires qualifications and involves dealing with numbers, facts, abstract ideas, or people.

At the hearing, the judge will ask you to describe the jobs you worked in the past. You’ll have to describe the physical requirements, whether you had to go through special training, how long did it take you to learn your job, and if you managed other people.

They might even ask you about any gaps in your resume or why you quit a particular job.

The expert will then classify each job based on the level of exertion and skill, and use this to conclude if you can do your old job. You should pay extra attention to how the expert describes your jobs and make sure that their descriptions are correct.

Questioning The Vocational Expert

Once you testify, both the administrative law judge will question the expert witness. The questions in a disability claim are usually structured as hypotheticals.

The first person who gets to question the expert is the judge.

The judge’s line of questioning

For instance, a judge might formulate a question such as:

Consider an individual with the same age as the claimant, the same level of education, and the same work history. Can that individual perform only unskilled sedentary work, and are there any jobs available in the current economy that they might be able to perform?

The expert will then identify the jobs they think the hypothetical individual can do. They’ll provide the code of each job and the number of jobs in your area.

By referring to the SSA’s assessments and your doctor, the judge will proceed with creating more hypothetical questions. For instance, if you have a limited range of motion and ability to lift objects, the judge might pose a question such as:

Consider an individual with the same age as the claimant, the same level of education, and the same work history. This individual can only sit for four hours and might occasionally be able to lift 10 pounds. Are there any jobs available that this individual can perform?

Once again, the expert will consider the hypothetical scenario and give their opinion.

When the judge states they have no further questions, you or your attorney (if you have one) will get the chance to perform a cross-examination.

Your attorney’s questions

The goal here is to perform a cross-examination that eliminates the jobs that the vocational expert claims you can do. The best way to do this is to provide more limitations that the expert has to consider.

For instance, while answering the judge’s questions, the expert may have concluded that you can work a sedentary position such as secretarial work. Taking this into consideration, an attorney may ask the expert further questions that include the limitations not mentioned by the judge, such as your inability to bend. They may ask the following:

Consider an individual with the same age as the claimant, the same level of education, and the same work history. This hypothetical individual cannot bend. Is such an individual capable of performing secretarial work?

Since this job requires bending, the expert might then conclude you are unable to perform the job. The attorney will pose similar questions until they effectively eliminate all the jobs identified by the vocational expert.

If you don’t have an attorney, you may question the expert yourself. However, formulating the right questions requires knowledge of disability law, which is why we don’t recommend attending the disability hearing without legal representation.

Asking The Right Questions

Even though the SSA hired the expert, it doesn’t mean you should view them as your opponent or fear them. They’re only there to determine the material facts of the case.

With the right set of questions, they might support your claim if there are no jobs you can currently perform. This is why we can only advise you to consult an attorney before your disability hearing.

It’s your future hanging in the balance, and with an experienced disability attorney supporting you, you’ll get the most out of your hearing. They can prepare you to respond to the questions that the judge asks you, as well as cross-examine the vocational expert on your behalf.

In getting you closer to receiving the benefits you deserve, this can be an invaluable help.

Should You Have a Life Care Plan in a Personal Injury Case?

Mon, 26 Sep 2022 13:48:03 GMT

Life care plans are usually debated in many families when a family member is injured. One of the most common questions we hear is whether life care plan personal injury is favorable to pursue.

A life care plan can help injured individuals and their families secure the best long-term care possible, so you’re probably wondering if it can help your case too.

Fear not, because we’ll answer all the burning questions you might have regarding life care plan personal injury including life care plans in workers’ compensation cases.

What Is a Life Care Plan?

A life care plan is typically used to precisely quantify ongoing and future costs of care for an injured individual. Life care planners are certified vocational experts (or medical professionals) who have the necessary expertise to testify in court, usually on the side of the plaintiff.

With a life care plan, it’s possible to project future costs in many different categories, such as:

1. Medical expenses

2. Long-term or short-term nursing care

3. Modifying the injured party’s home or vehicle

4. Medical supplies and equipment

5. Lost earning capacity

6. Daily living expenses

7. Rehabilitation and physical therapy

8. Medications

When is a Life Care Plan Personal Injury Needed?

The answer to this question is that it depends on the medical facts of your case.

What do we mean by that?

It depends on your condition after the accident. A life care plan personal injury is necessary if a plaintiff suffered injuries considered catastrophic. This category may include spinal cord damage, traumatic brain injury, or amputation of any extremities.

Injuries such as these require significant future medical care.

A life care plan personal injury is also helpful for plaintiffs who received injuries that led to chronic pain or even reduced function of different body parts. These symptoms can cause a long-term disruption in the daily life of the injured person. Thus, a life care plan can ensure that the medical needs after an injury are properly addressed.

As a result, life care planning can significantly increase damages awarded to the plaintiff.

On the other hand, if the plaintiff’s injuries are minor and they’re expected to recover within weeks or a few months, filing a life care plan personal injury to prove damages might be redundant.

What About Workers’ Comp Cases?

To keep it as short as possible, the same reasoning as with regular personal injury cases applies to workers’ comp cases. If your work-related injury led to chronic pain or conditions which require constant future care, a life care plan is an absolute must.

For lighter injuries that have no impact on your long-term working capacity, you should settle for the run-of-the-mill workers’ comp benefits.

Who Are Life Care Planners?

For their testimony to stand in court, these experts require the necessary certification. While you might think life care planning experts are usually physicians, people with different occupations can become certified life care planners. For instance:

1. Nurses

2. Rehabilitation experts

3. Occupational therapists

4. Case managers

5. Social workers

6. Physicians

7. Psychologists and psychotherapists

If you have a particular injury, for instance, a debilitating knee trauma, it would be wise to hire an expert with a background in orthopedics.

The Methodology Employed By Life Care Planners

There’s a lot that goes into a life care plan personal injury. To help ensure the best care for their clients, they’ll leave no stone unturned while putting together a comprehensive report.

Typically, they start with a detailed review of the medical records of the plaintiff. Next, they interview the plaintiff, as well as their family members and healthcare providers.

The crucial part is determining the proper care required for a particular ailment, which makes it possible to estimate the costs of medical care from different providers in a single geographic location.

Estimating costs is a pretty comprehensive process and experienced life care planners usually account for everything. For instance, if estimating the cost of the surgery, they’ll also break down additional costs such as the charges for anesthesiologists, equipment, and even any post-op medications.

Life care planners also have to determine the life expectancy of the plaintiff and determine how significant is the loss of earning capacity. Furthermore, they’ll attempt to quantify the suffering and pain caused by the entire personal injury process.

Last but not least, they usually perform a comprehensive analysis of the plaintiff’s ability to perform daily activities. What’s more, they’ll review the accommodation, transportation, and such of the injured person.

How High are The Settlements?

There are too many factors involved to provide a definitive answer. Every injury is different, and life expectancies can vary from person to person, making it impossible to come up with exact numbers. Still, disabled plaintiffs will usually be taken care of for the remainder of their life.

An important thing to note here is that the settlement is usually awarded in the present value of the costs.

What does this mean?

Present value encompasses two different elements:

1. The projected cost of each service/item in the period when they’re going to be incurred

2. The interest rate on the amount paid out now to pay for future expenses at a different date

The idea behind this is to compensate the plaintiff for the costs of future medical care. Additionally, by using the statistics of the rates of medical inflation, life care planners help mitigate the problem of the inflation of medical costs. For example, a service that costs $1000 now might cost $1,500 in a few years.

Taking The Confusion Out of Personal Injury

For serious traumas, life care plan personal injury is the only way to ensure the injured parties are fairly compensated for their pain and suffering. But it’s not just compensation - it’s a small piece of comfort and assurance that the families and the injured person themselves don’t have to worry about how they will cover the extensive medical expenses.

However, life care plans are not just about covering current medical care and long-term care.

They can also ensure that your or your family member’s quality of life is the best possible regarding the circumstances, whether it’s assisting with living conditions or finding the optimal care facility.

With a proper life care plan personal injury, your family members also have a piece of mind, knowing that a loved one is taken care of in a way that makes life a lot easier to bear.

Everything You Need To Know About Functional Capacity Evaluation

Mon, 19 Sep 2022 09:35:00 GMT

Workplace injuries happen all the time. In 2021 alone, per 100,000 workers, 23.000 suffered minor, while more than 600 suffered major injuries.

Because work-related injuries are a common occurrence, the US government developed workers’ compensation systems. Injured workers can rely on these benefits to recover from their ailments in peace without worrying about medical costs or the financial repercussions of their injury.

Workers’ comp is a ‘’no-fault’’ system, meaning that your employer doesn’t have to be found negligent for you to receive the benefits. However, employers will often try to dispute this coverage to save money through their insurance company.

If you suffered a workplace injury, you might be required to take a functional capacity evaluation. which might help to prove and objectively quantify the nature of your injury. Since this evaluation determines the actual impact of your disability on your work-related activities, it can help or harm your claim.

Continue reading as we break down the functional capacity evaluation and everything it entails.

Functional capacity evaluation defined

This evaluation is a series of tests designed to gauge a worker’s physical abilities, conducted by a certified evaluator. In other words, functional capacity evaluation is a surefire way to provide neutral information on the severity of the injury or illness.

The tests that the evaluator performs determine:

1. Physical strength
2. Ability to lift and carry objects
3. Range of motion
4. Stamina
5. Flexibility

This evaluation is necessary to quantify how injured a worker is and how much their limitations affect their working ability. Thus, to assess the correct level of benefits, a professional has to evaluate the worker’s ability in a standardized manner.

You won’t be simply labeled as injured because every injury is different, so the evaluation will match your ability to the demands of your job. The tests you go through will be tailored around your specific injury and the job itself.

For example, if your job involves carrying heavy loads over long distances, you’ll be tested on your ability to walk and carry heavy objects. If the evaluation shows you can’t perform this task, you might not be able to perform the same duties but you might be able to handle a less physically demanding job.

What happens during a functional capacity evaluation

If an independent medical evaluation required by the insurance company of your employer shows that you’re able to return to work, you might have to go through functional capacity tests to receive clarification on your current condition.

On the day of the evaluation, the person performing the assessment will review your case and allow you to ask any questions. Next, they might even review your medical records and perform additional musculoskeletal screening.

After you fill out the paperwork, the tests can begin.

As we previously mentioned, the nature of your work-related activities will determine the tests you must undergo. If you lift heavy objects, you’ll have to lift weights, but if your job heavily relies on cognitive function, your cognitive abilities will need to be tested.

For instance, the evaluator might ask you to:

1. Undergo dexterity tests
2. Run on the treadmill
3. Stack boxes
4. Kneel
5. Lift weights
6. Balance
7. Take hand-eye coordination tests

These are just some of the tests you might undertake. The entire process might take upwards of six hours, taking part over two consecutive days.

The role of the evaluator isn’t only to instruct you. They’ll also observe your ability to perform these tasks, as well as your level of exertion and range of motion. They’ll take note of any symptoms, such as sweating or trembling while performing the exercises.

Since these tests are carefully designed not to exacerbate any conditions, the evaluator will ask you questions during or after the test to gauge the level of pain. Additionally, they will ask about your injury, your pain levels, and which activities make your symptoms worse.

After everything is done, the evaluator will create a comprehensive report based on the findings of the functional capacity evaluation. They’ll also give their professional opinion on whether you’re ready to return to your job and if so, in which capacity.

They’ll then send the report to the person who requested the assessment, which can then be used to modify, continue, or terminate your benefits.

The benefits of functional capacity evaluation

At face value, this assessment seems like it might harm your benefits, but in fact, it can help all parties involved. Your employer will most likely appreciate the information that you’re able to work to a limited capacity instead of not working at all. Additionally, a proper evaluation makes it easy to discern if you’re committing insurance fraud.

Ultimately, you’re the party that can benefit the most.

Functional capacity assessment can help determine the right time when you should return to work and in what capacity. This matters because returning to work too early or performing duties outside of your abilities might cause a reinjury, which could put you out of commission for a long time.

Additionally, this procedure can also keep your coworkers safe. If you can’t lift heavy objects, there is a risk of you hurting other employees. For example, you could drop a heavy box on your colleague’s foot. This evaluation helps clarify your limitations, thus keeping you and the people around you safe.

Figuring out the level of injury can be tricky, which often causes disputes between employers and injured workers. This evaluation helps clear any misconceptions by providing an impartial account of your capacity to work.

It also helps quantify the injury. For instance, two workers with broken legs might seem to have the same level of injury, but their fractures and job requirements might be completely different. A functional capacity evaluation helps diagnose the exact level of injury and its impact on an injured employee’s working ability.

It is a lot more accurate than self-reporting since it’s based on standardized tests, meaning it can help ascertain the right time when you should return to work.

Furthermore, you might require other forms of support, such as occupational therapy. A functional capacity evaluation report can help you receive the appropriate benefits which might help you recover faster.

Functional capacity evaluation is nothing to fear of

This particular evaluation is a major component of the entire workers’ compensation process. The problem is a lot of injured employees view it as something very frightening. In reality, it’s not always your employer that might ask for this evaluation to be completed.

If you have an attorney, they might even ask for a functional capacity evaluation themselves.

Why?

Quite simply, it can be beneficial to your case. With a comprehensive report on your limitations, an attorney can favorably interpret it and use it to bolster your benefits claim.

Regardless of the circumstances, we hope you got a better understanding of everything regarding this crucial assessment, and understand there’s nothing to fear. At the very least – consider it as a way to gain a better idea of how debilitating your condition might be.

What Happens To Medical Bills When Workers’ Comp Is Denied?

Mon, 12 Sep 2022 08:37:00 GMT

Getting injured at work is stressful enough, but filing for workers’ compensation benefits and getting denied can feel like an extra gut punch.

Even if you just filed your claim, your mind has probably gone on a loop and you’re thinking about different worst-case scenarios. One of those intrusive thoughts must have also been what happens to medical bills when workers’ comp is denied.

While this sounds scary, there’s no need to lose sleep over it. There are options available to you.

We’re going to explore what happens to medical bills when workers’ comp is denied and the alternatives to workers’ comp benefits that can help you cover your treatment. However, the first item on the bill is the workers’ comp, and why your claim could get denied in the first place.

The reason why your claim could get denied

Workers’ compensation is a safety net for individuals who experienced a severe workplace injury that left them unable to complete their work duties. In short, if your injury is severe enough to eliminate your earning power, you are eligible for workers’ compensation wage loss benefits.

The most common reason these claims get denied is that, for instance, the injuries have no connection to your work activities. The injuries might have occurred earlier, or they simply weren’t serious enough to warrant medical treatment, or they don’t jeopardize your ability to complete your work duties.

Lastly, claims can also get denied if they don’t contain the necessary information regarding your injuries.

It’s important to note that some injuries may be non-compensable, and the events surrounding your injury matter. For instance, an insurance company may decline your benefits if you weren’t clocked in when the injury occurred. The same thing can happen if you were engaged in personal affairs when you got injured, or if your injury was caused by your reckless behavior.

Workers’ comp won’t cover your injuries if you were committing a crime when the injury happened. Furthermore, if you failed to report the event on time or if your injuries were self-inflicted, workers’ comp might deny your claim.

Most importantly, for a successful claim, there must be witnesses to your workplace accident.

If you somehow get denied, we suggest that you don’t give up yet. While there are other solutions, you should only entertain them in the worst-case scenario.

What to do if your claim is denied

If workers’ comp denied your claim, not all is lost. So to answer the question of what happens to medical bills when workers comp’ is denied, you can still get your benefits if you’re familiar with the appeals process.

First, you can apply for claim adjustment with the Workers’ Compensation Commission (WCC). After that, the WCC will assign an arbitrator and a number to your injury case. You can request a hearing to discuss the details with your employer with the arbitrator present.

We recommend you ask for a hearing with a request for an immediate hearing to receive your decision as soon as possible (usually within 180 days).

In case the arbitrator still decides to stick with the original decision of denying your claim, it’s not over yet. You can try to appeal this decision by filing a petition for review within 30 days of getting denied by the arbitrator.

After closely examining the decision, the commissioners will set a date for the hearing. Before this date, you may submit a document that contains the written argument that supports your claim. When arguing your case at the hearing, you get as much as ten minutes.

This entire process will go a lot smoother if you hire a lawyer. A legal professional can help you prepare for the hearing and ensure that your claim is as strong as can be. A lawyer can help keep things fair since you won’t have to face the entire process yourself. Your employer will most likely have an attorney present, and there’s no reason why you should show up alone.

Alternative options

If things don’t go as well as expected, you might feel defeated as the question of what happens to medical bills when workers’ comp is denied is still in the air. Worry not, as alternative options do exist.

While insurance companies are not required to pay for the cost of medical bills for workers who got injured, they do have to cover the bills in case a workers’ comp denies your claim. This means you won’t need to pay treatment expenses out of your own pocket.

You have a few options available:

1. Group/personal health insurance

Group or personal health insurers are open to covering the accumulated medical expenses while your workers’ comp case remains unresolved. The same applies to your spouse’s group health insurance.

However, there are a few things you need to be aware of. You’ll have to file a dispute notice, and you will most likely have to give your consent to pay back the insurance company after receiving your settlement by signing a document known as a reimbursement agreement.

An experienced lawyer can help negotiate a lower amount you have to repay with the insurance company and possibly help you receive a fair workers’ comp settlement.

2. Medicaid and Medicare

If you don’t have a group or personal health insurance, Medicaid might settle your medical bills. However, it only applies to low-earning power workers with limited personal assets.

While Medicaid is better than paying out of pocket, there are some drawbacks. For example, the program is notorious for its low rates, which means you’ll have to settle for treatment of lower quality. A great number of medical providers also don’t accept Medicaid, so you’ll have to spend extra time looking for a provider.

With Medicare, on the other hand, it’s a lot easier to find a provider. However, the criteria to become eligible for this program are more strict. If you’re at least 65 years old, you’re eligible. But if you don’t meet the age requirement, you can receive Medicare only if you’re approved for disability benefits from social security.

Keep in mind that Medicare is only available 29 months after the injury.

Navigating the workers’ comp maze

Hopefully, this answers your question of what happens to medical bills when workers’ comp is denied. The path ahead of you isn’t easy, and navigating the workers’ comp maze alone would be overkill (especially considering that you’re already under a lot of stress).

Our advice is to hire an experienced lawyer from the onset of your claims process.

Not only will you feel more comfortable knowing you’ve got someone on your side explaining your rights and options, but the results will most likely be better. You’ll not only have someone representing you at the hearing, but you’ll walk away with the best possible settlement.

Types of medical billing fraud

Mon, 29 Aug 2022 09:18:00 GMT

Give a thief enough time, and they’ll find countless ways to commit fraud. With healthcare, knowing taxpayer money can be involved, they can get really creative.

These actions most commonly happen during medical billing – a process in which claims are generated and submitted to insurance companies to obtain payments for medical services. Generally, billing fraud involves a healthcare provider billing a patient for medical services they did not provide. However, fraud can take many forms, which makes it very difficult to identify.

You might think that this is not a big problem, after all, how much can it amount to?

You have to know that fraud in healthcare happens on a broad scale, and it’s not very easy to recognize or prevent, and taxpayers bear the damage of over $60bn a year.

Today, we’re going to explain the two most common methods of billing fraud, upcoding, and unbundling medical billing. Hopefully, by the end, you’ll have an easier time understanding sketchy billing practices, and ultimately, you might even be able to report them.

Upcoding medical billing

Upcoding refers to medical providers intentionally using an inaccurate billing code to receive an inflated reimbursement for a medical procedure. In short, they are charging for a higher level of service than the one they performed, thus fraudulently receiving more money.

In healthcare, billing codes simplify the billing process by helping identify procedures and services provided to patients. Every code correlates to a diagnosis, a service, and ‘’describes’’ the complexity of the work that a physician provided. Insurers use these codes to more easily ascertain how much they should pay for those services.

For instance, a healthcare provider might code the removal of a small cyst as a more demanding procedure to remove a larger cyst. This results in a significant cost difference and increases the provider’s profits at the expense of healthcare programs, patients, and taxpayers.

Unbundling medical billing

Similar to upcoding, unbundling medical billing is a fraudulent practice in which providers bill multiple-step procedures separately when they should all be a part of the same coded procedure. With unbundling medical billing (also known as fragmenting) providers can receive a higher reimbursement by billing bundled procedures separately.

A good example of unbundling medical billing is when a provider illegally uses separate codes for routine surgery. They might use unique codes for incision and suturing instead of using the appropriate billing code with a lower reimbursement rate.

Other forms of healthcare fraud

Unbundling medical billing and upcoding aren’t the only forms of fraud out there. One of the more shady ones is double billing.

As the name implies, it’s simply billing someone for the same procedure twice. It might happen when a healthcare provider bills the patient and the insurance company for the same service. Alternatively, different healthcare providers can double bill the patient for the same medical procedures on the same date.

Sometimes, providers might even take it a step further by using an individual code in the claim but then also using the bundled code.

Healthcare providers can also engage in bill padding by including unnecessary expenses to the bill such as medicine administration or consults. For instance, look no further than the provider calling in unnecessary consultations or asking for pointless examinations.

However, worst of all, providers can also include line items for services that were never provided, including visits and medicine.

Which providers are committing fraud?

If you think these are all isolated cases perpetrated by a few bad apples, think again. Fraud such as unbundling medical billing and upcoding is everywhere, regardless if it’s a large hospital or a home healthcare agency.

Physicians can misuse evaluation and management (E&M) codes used to describe the complexity of a patient visit to bill for more time than it took in reality. They might even use wrong modifier codes that indicate that they provided additional services when in fact, the services provided are covered by the standard code.

Hospitals might bill a procedure provided by a nurse (a lower-paying service) as if it was provided by a physician. Hospitals may also bill care at higher levels than was provided. The same applies to urgent care facilities which might bill for services that were more extended than those provided.

Even durable medical equipment providers aren’t exempt from upcoding as they might bill for more expensive items and equipment than was delivered.

Reporting healthcare fraud

While isolated cases probably happen, the fraudulent practices we outlined above are generally interconnected schemes that involve more than one individual. Unbundling medical billing and upcoding is often close to impossible to detect without the help of insiders – whistleblowers.

As you might expect, widespread schemes usually involve people who aren’t actively involved in fraudulent activities. People aware of fraud are simply too afraid to expose it. In most cases, they’re keeping silent to avoid employer retaliation.

Luckily, The False Claims Act (FCA) exists. According to this federal law, people and companies who try to defraud government programs are liable. More importantly, this law provides employees with a way to report fraud without the fear of retaliation.

The FCA protects whistleblowers from suspension, discharging, demotion, threats, harassment, or discrimination in terms of employment. Additionally, whistleblowers are also rewarded if they bring a claim against a provider trying to defraud the government. They are also entitled to as much as 30% of the total recovery.

Filing a lawsuit

A whistleblower who wants to reveal unbundling medical billing or upcoding must file a qui tam lawsuit which triggers government investigation. Qui tam lawsuit means that an individual is bringing action against an organization on the behalf of the government. The whistleblower is considered a relator and the government is considered a plaintiff.

The government will investigate the allegations made in the complaint, and they can either join or intervene in the lawsuit.

Nothing is set in stone, so the government might choose not to intervene in the qui tam lawsuit. In that case, the whistleblower can still pursue the case and recover the funds on the behalf of the government.

The legal team of the whistleblower might make use of medical billing and reimbursement experts such as the ones we have here at MBA to build a stronger case. These experts can testify to the value of the medical services provided in matters of improper coding or billing.

MBA supports legal teams during the research and discovery phases, and evaluates charges from medical providers and suppliers in highly complex cases.

Call us at (800) 292-1919 or fill out our contact form , and we can help you and your attorney pull the curtain off on unbundling medical billing and upcoding in your lawsuit.

What Is Medical Billing?

Mon, 22 Aug 2022 08:43:00 GMT

You’re most likely aware of what billing is. However, billing in the healthcare industry is a bit more complicated.

Medical billing is the process that ensures that healthcare providers get paid for their hard work. In short, billers submit claims to insurance companies in order to obtain payments for services rendered by healthcare providers and organizations.

Once they translate the services into billing claims, they continue following the progress of the claim so that the healthcare provider can receive reimbursement for the work they performed.

Let’s explore medical billing in a little more detail to find out how billers simplify the payment process in a healthcare organization.

The role of medical billers

Medical billing is a process that comes with a lot of responsibilities. Billers are the link that connects patients, insurance companies, and healthcare providers. Billing is one of those things that happen behind the scenes that patients know nothing about because their point of contact is a single person – the physician.

The process starts with collecting the necessary information, such as patient demographic, medical history, insurance coverage, and the services provided to the patient.

Medical billers are the ones who rummage through the medical charts and insurance plans of the patient to validate the coverage of services. Only then do they generate the claim and submit it to the insurance company. Next, the insurance company approves the claim and sends it back to the biller with the amount they agreed to pay.

Billers also have to prepare the patient’s bill. They deduct the amount covered by insurance from the total cost, and factor in deductibles, copays, and outstanding patient balances.

Once all payments get posted and reconciled, medical billers finally send an invoice to the patient.

Medical billing is a multi-step process that needs to be taken care of in as short of a time frame as possible. Most state laws dictate that insurance companies have to pay claims within 30 and 45 days. Insurance companies often impose claim deadlines. If billers miss those deadlines, their claim will get denied without the option to appeal.

It’s just not deadlines that medical billers need to worry about. They also need to be as precise and effective as possible. Errors at any stage of medical billing can have disastrous consequences, both financial and in terms of administrative workload.

Medical billing can be broken down into two stages: front-end and back-end billing.

Front-end medical billing

This stage takes place pre-service and involves front-office staff. The staff completes all the patient-facing activities that are essential for accurate medical billing. The front-end stage consists of the following activities:

1. Registration

The processing of the claim begins as soon as the patient makes an appointment. This is when the staff obtains information such as patient demographics and insurance information.

Alternatively, the patient can also fill out a registration form once they arrive at the location.

Collecting accurate data is crucial in determining the patient’s eligibility and benefits.

2. Verifying insurance eligibility

The front office staff has to confirm if the patient’s health plan covers the services. This process includes verifying eligibility effective dates, plan benefits, patient coinsurance, copay, and deductible in regards to the place of service and specialty.

Pre-authorization is often required as a contingency of payment for medical services outside the primary care setting.

3. Point of service collections

Next, the staff gets informed of the financial responsibility of the patient. Thus, the biller can collect the deductible, coinsurance, copay, or full balance while the patient is still present (either during check-in or check-out).

4. Superbill generation

A superbill or an encounter form is generated for each patient encounter. It contains patient demographics, an area where the physician can write diagnoses, and a list of common services.

When the encounter is complete, the provider ticks the appropriate boxes and signs the form to corroborate that the services were performed and may be billed.

5. Checkout

At this stage, the staff makes a follow-up appointment and ensures that the encounter form is filled out.

As the patient checks out, medical records are sent to the medical coders who convert the information into medical billing codes.

Back-end medical billing

The level of complexity increases drastically during the back-end billing. It starts after the patient visit and once the medical coders have completed their tasks. The billing process then continues in the back office, and it consists of:

1. Charge entry

By using the information in the encounter form, the charge entry staff inputs charges, along with any payments made by the patient, into the practice management system.

This is the opportunity to check if there is any missing information in the superbill. For instance, if any of the diagnoses are missing, they’ll have to ask the physician for more information.

The charge entry staff also reviews charge captures to ensure all receipts get added when patient charges are reconciled

2. Claim generation

With the superbill data available, medical billers can finally prepare the claim by including all the patient information, essential provider information, and the dates of the service.

All of this information is converted into a claim and sent to the insurance provider.

3. Claim scrubbing

Scrubbing is a process used to detect any errors in medical billing codes. Sometimes, medical billers complete this by themselves with the help of claim scrubbing software that detects errors automatically.

It’s also possible to send the claim to third-party companies known as clearinghouses that specialize in reviewing medical claims.

4. Claim submission

Once the claim is ‘’scrubbed’’, it can be submitted to the insurance company. Nowadays, this process is usually completed automatically through software that meets electronic filing requirements.

Alternatively, medical professionals can file claims through clearinghouses.

5. Claim tracking

Once the insurance company receives the claim, adjudication officially begins. Adjudication is a review process in which the insurance company decides whether the claim is valid and if they should pay it.

Medical billers track the status of the claim daily.

Once the insurers complete the adjudication, they generate two statements:

1. Electronic Remittance Advice (ERA) is sent to healthcare providers that details which services were paid, whether additional information is required, or why the claim was denied.

2. Explanation of Benefits (EOB) sent to patients.

6. Payment posting

Once the ERA, accompanying checks, and direct deposits are received, healthcare providers are required to post payments.

Medical billers are crucial in this process as they match payments to the respective accounts and reconcile payments against the claim. They also confirm if the data from two insurance statements matches the payments.

7. Patient payments

When ERA gets posted, patient statements get set to all outstanding balances. These statements contain the date of service, information about services performed, insurance reimbursement received, as well as which payments were collected, and why the patient’s balance is due.

Once a patient makes the payment, it needs to be posted and balanced.

8. Denial management

Denied claims happen all the time in medical billing. The ERA contains denial codes and an explanation of why the claim was denied. The billing staff can then use this information to check whether more information is required and if they can correct any errors, or if they should appeal the denial.

9. A/R collections

Medical billers are also in charge of managing delinquent accounts and following up with patients who didn’t make the required payments after a set period.

This process can include offering financial conveniences to patients to accelerate collections, for instance, payment plans or online payment methods.

Once the payment is successfully collected, medical billers submit the revenue to A/R management.

The backbone of healthcare

Medical billing is the bridge between a medical provider, the patient, and the insurance company. Without billers, the payment process in healthcare would be a mess as doctors wouldn’t be able to focus on treatment, and patients would have another worry on top of recovery.

Doing this job isn’t easy as it requires a wide range of skills, so the choice of a medical billing professional does matter. Medical billers not only make the lives of physicians and patients easier, but they also optimize revenue performance for the healthcare provider.

So the next time you’re at the doctor’s office, remember just how important these underrated medical professionals are and take a moment to appreciate their hard work.

How To Approach Ambiguous CPT Modifiers?

Mon, 15 Aug 2022 09:08:00 GMT

In a perfect world, CPT modifiers are used without any issues to add additional information regarding a service provided by a physician. Sadly, we don’t live in a perfect world, and certain modifiers like modifier 79, for example, can cause significant billing problems.

The thing is, the definition of some modifiers is very ambiguous so the confusion around them is justified. That is to say, if you’re a medical biller and you’re puzzled by these modifier codes, it might not be just you.

Making a mistake can have serious consequences and result in denied claims. Thus, knowing whether to use modifier 79 over modifier 59 is vital if you don’t want to end up in a world of trouble.

We’ll do our best by clarifying the definitions of different codes and explaining when you should use each one.

What are the most problematic modifiers?

The ambiguity in the definitions we mentioned refers to CPT modifiers. 58, 78, 79, 59, and 24 that are applied to surgery claims. These definitions are taken from the official site of the Center for Medicare and Medicaid Services (CMS):

1. Modifier 24 : Unrelated evaluation and management (E/M) service by the same physician during a post-operative period
2. Modifier 58: Staged or related procedure or service by the same physician during the post-operative period
3. Modifier 59: Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day
4. Modifier 78: Unplanned return to the operating or procedure room by the same physician following the initial procedure for a related procedure during the post-operative period
5. Modifier 79: Unrelated procedure or service by the same physician during a post-operative period.

Breaking those definitions down, it’s easy to see where the confusion comes from. For example, the wording of modifiers 78 and 58 is unclear. If we were to go by what’s presented in the CMS definitions, both modifiers apply to the post-op period and could easily refer to the same procedure.

The reason why this trips up medical professionals is that even though modifier 58 applies to staged procedures and 78 refers to unplanned procedures, the former also uses the phrase or related. This could indicate that both modifiers could be used interchangeably for a related, unplanned procedure.

Others, like modifier 79 aren’t exempt from confusion either, which is why we will break down each of them in detail.

Modifier 58 explained

As described by CMS, this modifier indicates the procedure was:

1. Planned, either at the time of the first procedure or prospectively.
2. More extensive than the first procedure.
3. For therapy after a diagnostic surgical procedure.

However, the CMS doesn’t clarify if the conditions described above are separated by the words and or. This is why medical professionals generally assume that the conditions described should be separated by or. In other words, any of the conditions can justify the use of this modifier.

To clarify it further, modifier 58 is always about a patient returning to the OR as it refers to the related procedure in the post-op period. Additionally, the key factor in determining whether a procedure is covered by modifier 58 is if the doctor knew about the medical procedure before the first, related operation was completed.

A good example of such a scenario would be if a surgeon performed a biopsy. Let’s say that the sample was found to be cancerous, and afterward, the same surgeon did a second procedure to remove the tumor. In this case, modifier 58 needs to be used because it’s apparent the surgeon was aware that the biopsy might result in a more extensive procedure.

Modifier 78 explained

The CMS states the following:

1. The subsequent procedure must take place in the operating room.
2. The second procedure must be related to the first.
3. The use of modifier 78 isn’t limited only to complications.

In conclusion, this modifier is to be used for related surgery that wasn’t planned at the time of the first procedure.

While this one is similar to the 58 version as they both cover procedures in the OR during post-op for a related procedure, modifier 78 is used when the doctor didn’t plan the second procedure until the first one ended.

For example, if a doctor performs a C-section and bleeding occurs that prompts the surgeon to call the patient back into the OR, it means the second procedure was unplanned. Since the same doctor will perform the surgery, it means that this modifier applies to this claim.

However, modifier 78 won’t apply if the procedure isn’t performed in the operating room.

Modifier 79 explained

Modifier 79 can be confusing too.

While it covers the procedures done in the post-op period by the same physician, modifier 79 is applied to unrelated procedures. To put it in another way, you shouldn’t worry about whether the procedure was planned or unplanned when there is no connection between the two operations.

The best example of when you should use modifier 79 is when in a situation where a doctor performs exploratory surgery on a lump on a patient’s leg. The growth might turn out to be a benign cyst. Later on, if the patient returns to the same doctor during the post-op period to have another unrelated growth removed, it’s best to use modifier 79.

Modifier 24 explained

This one can be easily distinguished from other modifiers as it refers to unrelated E/M services performed by the same doctor post-op. If an E/M service is to be billed under this modifier there needs to be documentation proving that this service isn’t a part of the post-op.

For example, when a doctor performs surgery on a patient’s rotator cuff and afterward checks the patient’s knee pain, modifier 24 applies to the second E/M procedure.

Modifier 59 explained

While for some this modifier might cause confusion, it’s pretty simple to differentiate it from the other ones. Modifier 59 refers to a non-E/M service performed on the same day. In comparison, modifiers 79, 78, and 58 refer to unrelated procedures or E/M services performed post-op.

However, the point of confusion is usually regarding modifier 79. Both modifiers can refer to the same set of procedures that occur during the post-op period.

This is because the phrase same day service can also refer to a post-op period because this period can technically start on the same day.

Still, for the same day non-E/M services, it’s recommended that you use modifier 59 as the phrase ‘’same day’’ is more specific. Additionally, if a different injury/body part from the first procedure was operated on in the same session, modifier 59 can also be applied.

For example, if the same doctor removes a growth from a patient’s abdomen and performs a small injury on the patient’s toe in the same session.

Removing ambiguity from billing

Some modifiers are mixed up more often than others. For instance, modifier 79 is often confused with 59. The same goes for modifiers 78 and 58. It’s our hope that by adhering to this guide, you’ll be able to look past the ambiguity and know exactly which modifiers to apply.

Clearing up the mess with modifiers that seem to overlap with each other is not only going to make your life easier, but it will also stop you from royally messing up your billing procedures.

As far as your employer is concerned, they will appreciate the fact that there are fewer denied claims, but more importantly – that the rates of reimbursement are what they should be.

Coders Play an Important Role in Revenue Cycle Management and Compliance Efforts

Mon, 08 Aug 2022 09:00:00 GMT

The medical field is chockfull of crucial non-clinical roles. Even though the general public is familiar with medical billers, coders rarely get mentioned. However, coders play an important role in the healthcare system.

For starters, they translate all that medical lingo into universal medical codes for accurate medical billing. That’s pretty big in itself but they also do a damn good job when it comes to identifying devastating non-compliance issues.

With this post, we’ll explore why coders play an important role in the healthcare system and what makes them an indispensable part of the medical billing process. First, we’ll focus on what revenue cycle management (RCM) and compliance efforts are, and address both the respective roles of coders and medical billers

What are revenue cycle management and compliance?

Revenue cycle management is the process of tracking patient care from the beginning to the very end by leveraging medical billing.

In other words, RCM is a link between the clinical aspect of healthcare and the business side.

It connects administrative data like the patient’s insurance provider with the treatment that the patient has received.

Another important aspect of RCM is communication with insurance companies. As the patient schedules the appointment, the staff checks their coverage before they even walk into the medical practice.

Once the treatment is complete, medical coders step in to categorize the nature of the treatment. The summary is then passed on from the hospital to the insurance provider.

On the other hand, compliance efforts refer to monitoring rules, laws, and regulations to protect the healthcare provider from noncompliance and risks by identifying issues in compliance management functions.

Medical billers and coders in RCM

Both billers and coders are deeply familiar with coding and billing guidelines and reimbursement policies. However, what they do is very different.

What medical billers do

Medical billers prepare billing claims and submit them to insurance carriers. They are responsible for ensuring that the healthcare provider is correctly reimbursed for the medical services they provide. After the patient is done with their appointment, the healthcare provider assigns procedure codes to the procedure, which are used by insurance companies to assess the associated coverage.

Medical billers are involved in multiple processes, such as:

1. Patient registration
2. Verification of eligibility and benefits
3. Charge entry
4. Posting payments
5. Rejection corrections
6. Denial management
7. Account receivable management

Any incorrect information in the claims to insurance carriers will result in denied payments.

What medical coders do

In short, medical coding refers to converting important, yet complex medical information into uniform medical codes.

These codes are then used for documenting medical records and for billing purposes.

This system ensures a seamless transfer of medical records along with a more efficient way to track the health records of patients.

Coders work behind the scenes from the start of the revenue cycle. Healthcare providers send detailed medical reports to coders which include the patient’s condition and diagnosis as well as any prescription. Coders then translate all that information into alphanumeric codes and ensure that the medical records are properly documented and the billing information is accurate.

Any errors in the coding can have severe consequences such as:

1. Claim denials
2. HIPAA violations
3. Loss of revenue
4. Lawsuits
50 Federal fines

When a claim gets denied by the insurance provider, the entire revenue stream takes a massive hit. To make matters worse, it takes a lot of time and effort to identify the issue and resubmit the claim. As the cherry on top, that also doesn’t ensure that the claim is paid in total as insurance providers might only agree to make a partial payment.

It’s also important to note this doesn’t only affect the healthcare provider and their bottom line, The patient care itself is compromised too. In turn, patients that were affected by coding errors can file for malpractice. So on top of the direct disruption in the revenue stream, a hospital, for example, might also end up paying hefty fines and legal fees.

Hence, coders play an important role in discovering non-compliance issues.

The link between coders and compliance efforts

Coders handle multiple documents and review them to determine if the codes check out. This is why they can spot a wide variety of compliance problems.

In the revenue cycle, for example, coders can identify omissions of legitimate charges or discover that the charges themselves are incorrect. They might uncover incorrect terminology or the incorrect use of abbreviations in medical records.

Additionally, they might even run into a case of clinical plagiarism which doctors sometimes resort to. For instance, a doctor might copy and paste content from another doctor’s record and include it in their record as if they ordered or performed that work. These are all issues that could lead to liability or non-compliance.

Coders can recognize these issues and raise a concern, which can then further be investigated by professionals dealing with compliance and risk management. Some examples of risk management issues that coders can help discover include:

Untimely preparations of reports

The preparation of reports can easily become a major risk management problem. For example, if there is a complication during surgery and operative notes aren’t dictated 30 to 40 days until the patient is discharged, there will be a big problem if the case goes to court.

The surgeon might have a harder time proving that he could accurately describe the procedure because the report is old and they had completed additional surgeries before writing it.

‘’Biting’’ comments in medical reports

Any information in medical reports that don’t concern the patients are referred to by the coders as ‘’biting’’ comments. For example, a physician might call out a fellow physician for poor performance or insufficient preparation, or a nurse might detail abusive language from the physician.

Coders can then call attention to these progress notes so the risk management team can get involved in mitigating the problem.

Falls and injuries that aren’t reported to risk management

During treatment, it’s not uncommon for a patient to experience injuries or falls. Nevertheless, these events must be reported to risk management. The role of coders here is to report these instances and forward the information to risk management.

Nursing should, in theory, report all incidents. The reality is a bit different as mistakes can sometimes happen. If a coder did report the injury, risk management has the necessary documentation to contact the employees or the patient in a timely fashion after the incident.

The power of the code

While in most cases, codes might look like complete gibberish to mere mortals, they are at the core of medical billing. Coders and billers use them to ensure that you get properly charged for your treatment.

Both medical billers and coders play an important role in ensuring that all payments check out. But more importantly, they protect the patients from getting overcharged.

Furthermore, these medical specialists can help mitigate non-compliance issues because they’re right in the middle of the action. This is where they truly shine and where their skills come in. A mediocre coder might not have enough time to focus on risk management problems. But the one who is skilled enough to translate medical procedures into medical codes that also keeps an eye on compliance, risk management, and the revenue cycle is a force to be reckoned with.

If you needed additional persuading as to why coders play an important role in healthcare in general, not just in medical billing – this is it.

How To Find Out If You Have a Medical Lien Filed Against you?

Mon, 01 Aug 2022 09:02:00 GMT

Unfortunately, you can’t get medical treatment for free. The government, the state, or even your insurance has the right to claim the money from your personal injury settlement.

Why? Two words – a medical lien .

Let’s say you’ve been in a car accident and filed a lawsuit to pay for your hospital bills. It might be wise to learn how to find out if you have a medical lien filed against you as your personal injury settlement money might not belong only to you

The claims process can be stressful, especially when you have no idea if you’re even going to win your case. On top of that, you’ve got your financial state to worry about. Fortunately, we can help put your mind at ease as there are things you can do.

Let’s take a look at what a medical lien is, how to find out if you have a medical filed against you, and ultimately, what to do about it.

Medical lien and the process of subrogation in a nutshell

In short, a medical lien is a request for your personal injury money from your healthcare provider. In most cases, medical liens are a way for a hospital or a doctor to recoup the money for the treatment of patients who don’t have health insurance.

However, even if you do have health insurance, your settlement money can be claimed by your health insurance provider.

How?

Through a process of subrogation.

Subrogation is a right that allows insurance companies to seek repayment from your personal injury settlement. The strength and the extent of this claim might be different depending on your insurance company.

In some states such as Arizona or Kansas, subrogation clauses are not allowed as a part of insurance policies. Make sure to check the laws in your state to see if the insurance company has the right to claim your insurance policy.

What types of liens are out there?

Before we answer the question of how to find out if you have a medical lien filed, do note there are a few different types of liens. They mostly depend on who paid for your medical care, with the three most common types of liens being:

Hospital/Medical provider liens

In certain states, it’s common practice to file liens in case the patient doesn’t have health insurance. Liens are not put on patients, per se. Rather, medical providers attach liens to the injury claim.

The lien exists only to ensure that the hospital that treated you gets reimbursed for the services that they provided.

While that sounds scary at first, it means that the lien won’t affect your credit or your personal rating since it’s attached to the injury claim. Additionally, liens can’t be attached to assets, so you have an option even if you don’t receive any settlement money.

Depending on the provider, some might ask you to sign a lien letter stating that you’re consenting to give the hospital the lien against your settlement to pay for your medical bills.

A lien won’t be enforceable if it doesn’t follow the requirements of the hospital lien statutes. For instance, a lien must include your proper name and address, name and address of the hospital as well as dates on which the hospital provided you with medical services. If any of these are missing, the medical provider won’t be able to enforce a lien.

Government liens

Depending on the circumstances, if the government paid for any part of your medical care, they have the right to get a piece of the action back in case you file a personal injury claim against a different party.

Based on the type of program, different government agencies like Medicare have different rights regarding your settlement money. Some have the legal footing to recover a part of the proceedings.

Workers’ compensation liens

To compensate injured workers, there is the aptly titled workers’ compensation law. If you get injured in the workplace, you can collect money under the workers’ compensation policy to cover your medical costs. To avoid windfall and stop you from profiting from your injuries, you can’t get your workers’ compensation while also raking in the settlement money from suing a third party. According to the law, your insurer can register a claim against your personal injury action and get reimbursed out of the proceedings. Now that you know how liens work, it’s time to learn how to find out if you have a medical lien.

Looking up a lien is simple

If you have a sneaking suspicion that a medical provider that treated you has placed a lien on your personal injury claim, you can find out the status in a few easy steps:

1. Go to your County Clerk’s website
2. Find the online search section
3. Enter your last name and the name of the hospital into the search box
4. If the information isn’t available, check if your county has any details regarding internet searches for liens. For instance, Shelby County, Tennessee, allows you to look for hospital liens through Circuit Court’s online case search tool.

If you can’t find any info online, you can look for it in person. Since hospital liens are filed in the county where the hospital is located and where you reside, you can find copies of any liens filed in your county by going to your county’s Circuit Court.

That’s basically how to find out if you have a medical lien filed against you. If you do, then it’s time to get into gear.

Negotiating a medical lien

A lien can take a lot out of your injury settlement. Luckily, you have options so it’s possible to negotiate the terms with the lien holder. This applies in two cases:

1. If you end up losing the claim
2. If the terms are unfavorable

If you lose the motion, you’ll still be responsible for paying your healthcare expenses. If you have no money to cover the expenses, the lien holder will need to take you to court or collections.

Unfavorable terms are also a reason to consider negotiating since in some cases, a medical provider might charge a patient more for a particular treatment than they would charge an insurance company.

However, most medical lienholders want to recover just a portion of the money in a reasonable time. Taking the patient to court or the collections takes a lot of time, and ultimately, they might even get less money than they originally intended

Because of that, they will most likely be open to negotiations

The right time to get help with a medical lien

Hopefully, this explains how to find out if you have a medical lien in your name. What you do with that information makes all the difference in whether you’ll end up paying more or if you’ll be a part of a costly litigation process in the future.

Medical liens can be a tough cookie to crack without an attorney at your side. Even if you’re aware that a lien can be negotiated, chances are, you might not know which steps you should take.

By hiring an experienced attorney, you position yourself to get the best terms possible. If you lose the case, your attorney can help you get a payment plan so you can pay off your medical expenses over a specified period of time.

What Is A Medical Lien – Everything You Need To Know

Mon, 25 Jul 2022 09:01:00 GMT

Do you know what happens if you get hurt in an accident and you have no health insurance? Will you go bankrupt trying to pay the necessary medical bills? If you’re struggling with these questions, you’re going to appreciate learning what is a medical lien.

The sad fact is that even if an individual gets injured due to the neglect of a different party, they’re still responsible for their own medical bills. To mitigate this issue, healthcare providers can choose to provide medical care in return for a lien.

Let’s take a closer look at what is a medical lien and how it can help you cover your medical expenses.

The definition of a medical lien

To answer the question of what is a medical lien is fairly simple:

It’s a legally binding agreement between a healthcare provider and the patient. It gives the healthcare provider the ability to recoup money owed for treatment by placing a request on the patient’s personal injury claim.

In other words, the patient gives the provider a lien on the proceedings of the case while the hospital provides medical services on credit, so to speak. When the case comes to a close, the healthcare provider then exercises their rights, as per the lien agreement, and recovers the costs of healthcare they provided.

While that answers the question of what is a medical lien, there’s still a bit more to unpack. More precisely:

Who gets paid first once the settlement is over?

The healthcare provider gets their piece of the cake first, even before the patient (aka. the case’s plaintiff). After the contract is signed, the medical provider will send out a notice of debt to all parties involved. This is called perfecting the lien and it guarantees that the lien holder will be paid first from the verdict or the settlement.

For individuals who have no means of covering the cost of their medical treatment in case of an accident or an injury caused by another person, medical liens are a godsend. However, this legal remedy might not be available in all cases.

Are liens available with every healthcare provider?

Depending on the provider, no. You see, medical liens are a known risk for healthcare providers. To completely understand what is a medical lien and why it’s a risk for the hospital, you’ve got to know one thing – a lien is not a debt.

It doesn’t attach to the personal property or real estate of the patient, only to the proceeds of the settlement. This means that if the plaintiff loses, the healthcare provider can receive money only from the plaintiff.

We already mentioned that victims in such cases usually have severe financial limitations, so they will likely have a problem paying for those medical bills.

In such a case, a medical institution or a provider will have no other recourse but to send the bill to collections in this case, ultimately, getting only a fraction of what they are owed.

Do people with insurance need medical liens?

Being familiar with what is a medical lien isn’t as important for people who have health insurance as the health insurance company can cover the medical bills in case of an injury or an accident.

Yet, even the plaintiffs that didn’t turn to a medical lien still might need to give up a part of their settlement money due to subrogation.

Subrogation is usually a part of the insurance policy itself and it states that the insurance company has the legal right to collect damages on behalf of the other party (in this case, the plaintiff). This is a way for them to recoup their losses.

Many people find subrogation unfair because a large part of their settlement money goes to a third party. Without it though, the victim would basically have a financial advantage from an injury. Their medical bills would be covered by the insurance company and if they win their claim, they’d walk away with a lot of extra money.

This brings us to our next point:

How much can a healthcare provider take?

There is quite a bit of difference between insured and uninsured victims. While in most cases, there is a state limit on the amount the insurer can recoup from the settlement money, there is no such limit regarding liens.

By now, you already know what is a medical lien and that it’s legally binding; hence the healthcare provider has the legal right to the full amount of the lien. But what happens if the injury settlement can’t cover the full amount?

If the settlement money ends up being less than projected, the healthcare provider can pursue the patient for the remainder of the amount.

What if the victim loses the case?

If everything goes south and the plaintiff ends up losing the case, they are liable for their healthcare expenses and will need to pay them eventually. They will still owe a hefty sum to the healthcare provider and will be personally responsible for paying it in total.

When we explained earlier what a medical lien is we mentioned how the healthcare provider is entitled to their legal rights. Even if the victim doesn’t have the money to pay, the lien holder can take the patient to court or collections.

However, it’s not all that scary as liens are quite different from debts and it’s still possible to renegotiate the amounts once the worst happens.

Medical liens negotiations

Generally, all contracts can be negotiated and renegotiated. The same goes for liens. Being aware of what is a medical lien is important so you can also know your options.

Even before a lien is signed, the terms of the contract can be negotiated. In most cases, they can be negotiated to tip the favors toward the victim. Yet, oftentimes healthcare providers will stay away from entering negotiations to avoid the hassle of adjusting the terms of the lien offer.

However, most people without health insurance would simply find a healthcare provider that offers a more favorable agreement if they knew what is a medical lien.

Contracts aren’t set in stone, so the terms can be altered even after the lien is signed (naturally, if both parties agree). This usually happens in case a victim doesn’t receive their injury settlement as planned.

Because taking a patient to court would be time-consuming and taking them to collections would probably end up yielding less money, the lienholder will be open to negotiations. They’ll either agree to reduce the owed amount or more commonly, agree to a payment plan that lets the victim pay over a specified timeframe.

Those are the available options you can pursue once you are familiar with what is a medical lien.

Contact an attorney

The fact that medical liens are negotiable means that you can reach a compromise with your healthcare provider and find the perfect amount favorable to both parties. What’s even better is that it’s possible to negotiate the agreement before the case even settles. Generally, doing so can save you a lot of money in the long run.

While you can go about the negotiation process alone once you fully understand what is a medical lien, it may not be the best idea. The proceedings will be highly technical so we recommend looking for legal counsel specialized for these exact events.

An experienced attorney can give you the necessary advice and guidance that will, ultimately, make a world’s difference between a tough legal situation and a medical lien that’s manageable for you.

Working Together: A Guide for Medical Experts and Medical Billing Experts

Mon, 11 Jul 2022 09:28:00 GMT

Medical experts provide opinions in litigation involving personal injuries, wrongful death, medical malpractice, sexual and domestic abuse, and other medical harms. They help lawyers establish economic and noneconomic harms, usually by offering opinions about the cause of an injury, the necessity of medical treatment that the victim received for that injury, the likely need for future treatment.

Medical bills are part of the injury victim’s economic damages. To recover medical bills, most states require the plaintiff to prove that the medical expenses were necessary and reasonable. Medical experts — usually treating physicians — can testify about the necessity of treatment. However, lawyers generally rely on medical billing experts to prove that billings were reasonable.

Medical Experts in Litigation

Personal injury cases typically depend on medical experts to establish the extent of an accident victim’s injuries. Treating physicians are the most common medical experts in personal injury cases. In federal court, a treating physician is classified as a non-retained expert. Non-retained experts are not required to produce the detailed reports that civil procedure rules demand of retained experts. Treating physicians testify about the injuries they observed, the diagnosis they made, the treatment they rendered, and the recommendations they made for future treatment.

A treating physician might also give causation testimony by stating whether the injuries the physician observed are consistent with injuries that could be caused by the car accident that other witnesses describe. When a treating physician is uncomfortable expressing opinions about causation, or when a judge rules that the treating physician may not do so, it may be necessary to retain a medical expert to give that testimony. Retained medical experts also testify in personal injury cases when a specialist needs to be hired to opine about future treatment needs and the cost of such treatment.

Retained medical experts are common in medical malpractice litigation. Medical experts are hired as witnesses to testify about the standard of care that applies to a doctor who practices in a given specialty. The expert witness will also review the defendant doctor’s performance and express an opinion whether the defendant breached that standard of care.

Depending on state law, medical experts play varying roles in workers’ compensation proceedings. In most cases, treating physicians prepare reports that describe work-related injuries. They engage in functional capacity evaluations and define work limitations based on workplace injuries. Medical experts may play critical roles in assigning disability ratings. Some states give employees the opportunity to retain medical experts to conduct independent evaluations, while other states are more restrictive about the employee’s right to introduce the opinions of retained medical experts.

Sexual and domestic abuse lawsuits depend on medical experts to testify about physical symptoms of abuse and its psychological consequences. Lawsuits against institutions (including schools and churches) that employ sexual predators often rely on psychiatrists and other medical experts to explain the lasting impact of childhood sexual abuse on adult survivors.

Medical experts testify in wrongful death and survival actions to establish cause of death, the time span between the accident and death, whether the victim was conscious during that time span, and medical efforts to save the victim’s life. Wrongful death lawsuits often involve substantial medical bills for medical treatment prior to death that the victim’s estate seeks to recover.

Medical Billing Experts

Recovering medical expenses requires proof that the expenses are reasonable and necessary. A combination of medical experts and medical billing experts is needed to establish those elements.

The necessity of treatment is the province of a medical expert. Treating physicians are often in the best position to explain why the treatment they rendered was a necessary response to the injuries they diagnosed.

The reasonableness of medical expenses, however, is not usually an opinion that medical experts are qualified to render. Reasonableness is a function of two factors: the usual price for a service that the physician charges her other patients, and the customary price charged for the same service by other physicians in the community. A treating physician might be able to testify that about his usual charges but has probably not conducted the kind of expert analysis that is required to form an opinion about the customary charge.

Many courts have determined that medical experts cannot satisfy the Daubert standard when they propose to offer expert opinions about the reasonableness of their charges. Daubert requires expert opinions to be based on a reliable application of a reliable methodology to sufficient facts. The “sufficient facts” that support a reasonableness analysis are the prices charged by other physicians in the same geographic area. Basing an opinion on anecdotal testimony about the prices charged by one or two other doctors is not a reliable methodology.

Courts have ruled that experts in medical billing do not need to be doctors. Instead, they need to be trained in the science of medical billing. They need to understand how to compare medical records to medical billings. They need to understand Current Procedural Terminology CPT codes to determine whether the billing reflects services that were actually provided. They need to understand the rules that govern those codes to make sure that a biller did not charge procedures using separate CPT codes when they should have been charged using a comprehensive CPT code.

Medical billing experts gather sufficient facts to support their opinions about customary charges. They consult reliable databases that record the prices actually charged by physicians within a zip code for the same services or procedures that the injury victim received. They then use standardized methodologies to determine whether the charges in the medical billing fell within a range of reasonableness based on prices derived from the database.

Medical experts and medical billing experts have distinct but related roles to play in litigation. Medical billing experts do not offer medical opinions, just as medical experts do not offer opinions about the reasonableness of medical billings. Lawyers rely on both kinds of experts to recover full economic damages for injury victims.

Why Do You Need to Hire Both a Medical Expert Witness and a Medical Billing Expert Witness?

Mon, 04 Jul 2022 08:59:00 GMT

Personal injury cases require proof of liability and damages. To prove liability, lawyers need to establish that a negligent act or omission caused an injury. Medical experts are often crucial to proof of causation.

Some elements of damages, including pain and suffering, may require no expert testimony. Medical experts may nevertheless be needed to prove future damages, such as the need for future surgeries or the existence of a permanent disability that will cause ongoing pain and income loss.

Medical expenses incurred to treat injuries inflicted by negligent acts or omissions are recoverable as damages if they are reasonable and necessary. The necessity of treatment is usually established by the treating physician. However, courts have often ruled that medical experts are not the right witnesses to establish that medical expenses were reasonable. A medical billing expert is the proper witness to prove that element of damages.

Medical Expert Witnesses

Federal courts classify medical expert witnesses as retained experts or non-retained experts. Treating physicians are usually non-retained experts. They were hired by the patient to diagnose and treat an injury. The patient did not hire the doctor to testify in court.

Yet treating physicians often testify, usually by way of deposition, regarding the injuries they observed, the diagnosis they made, and the treatment they rendered. They may also testify that the injuries they treated are consistent with a particular event, such as a traffic accident. That testimony, coupled with the victim’s testimony that she was uninjured before the accident, will usually suffice to prove causation.

Treating physicians give expert testimony. When they explain a diagnosis, for example, they are rendering an opinion that is based on specialized training and experience that is beyond the knowledge of ordinary jurors. Some state courts classify a treating physician as a fact witness or a “hybrid” witness, but everyone recognizes that much of their testimony depends on their expertise.

Whether they are labeled fact witnesses, hybrid witnesses, or non-retained experts, treating physicians are not usually subject to the same requirements as a retained medical expert. In federal court, retained experts must prepare a report that satisfies federal discovery rules. Lawyers who plan to call non-retained medical experts must summarize their opinions but are not required to produce formal reports.

Retained medical expert witnesses are generally hired by lawyers rather than patients. They are hired to form and express opinions, not to treat the injury victim. They will often examine the injury victim, but they do so for the purpose of gathering facts that will inform their expert opinions. They might be hired to testify about the permanent nature of a disability, the need for future treatment, or whether the victim was injured by medical malpractice.

In federal court, medical expert witnesses who have been retained must prepare a formal report that describes the opinions they will express during their trial testimony and the factual basis for those opinions. State rules may or may not require the preparation of a formal report. If no report is required, lawyers will generally be served with interrogatories requesting a summary of each opinion the expert will express. Responding to the interrogatories may require an effort that is similar to preparing a report.

Medical Billing Expert Witnesses

Medical billing experts are always retained experts. They are retained by plaintiffs’ lawyers to prove the reasonableness of medical bills and by insurance defense attorneys to dispute their reasonableness.

The reasonableness of a medical bill depends on whether it represents the usual and customary charge for the same services by physicians in the same geographic area. The usual charge is the price that the treating physician charges other patients for the same service. The customary charge is the price that other physicians in the same community charge their patients for the same service.

As states have increasingly adopted some version of the Daubert standard of expert witness admissibility, it has become increasingly clear that medical experts are rarely able to give admissible testimony about the reasonableness of a medical bill. Expert testimony must be based on the reliable application of a reliable methodology to sufficient facts. Physicians who testify that their bills are reasonable are usually expressing a personal opinion, not an opinion based on a reliable methodology or sufficient facts.

Doctors rarely have more than anecdotal knowledge about what other physicians in the community charge for the same services. They do not base opinions about reasonable charges on reliable methodologies. Courts have increasingly decided that doctors cannot give admissible testimony about the reasonableness of medical billings.

Medical billing experts, on the other hand, use methodologies that have been proven reliable. Experts in the field have adopted a consistent methodology to inform opinions about reasonableness. The methodology requires a careful comparison of medical billings to medical records. If Current Procedural Terminology CPT codes in medical records do not correspond to services that were actually provided, the billing is likely to be inflated.

Medical billing experts also decide whether the correct CPT codes were assigned by the biller/coder. If a code describes a more complex service than the one provided, the billing will be excessive. If the coder used separate billing codes for services that should have been bundled into a single code, the billing will be unreasonable.

After determining that the billing is or is not accurate, a medical billing expert will consult reliable databases to determine the actual charges that other physicians within the same zip code have billed for the same services. The billing expert will compare the physician’s charges to physicians of comparable experience and will ask whether the billing falls within a reasonable range of charges for the same services. That analysis makes use of sufficient facts and a reliable methodology to produce opinions that courts will deem admissible.

Medical experts and medical billing experts have distinct roles to play in trials, but they are not interchangeable. By applying a reliable methodology to sufficient facts, medical billing experts can offer opinions about reasonableness of medical bills that medical experts are not qualified to render.

How Medical Billing Expert Evidence Is Admitted in a Medical Malpractice Case?

Mon, 27 Jun 2022 08:39:00 GMT

Liability in medical malpractice cases, as in other negligence cases, is established with evidence that a defendant breached the legal duty to exercise reasonable care to avoid foreseeable harms. Unlike other negligence cases, the defendant’s duty is established by a standard of care that must be proved with expert witnesses.

Proof of damages in a medical malpractice case, as in other negligence cases, may also require expert testimony. Medical testimony may be needed to establish the nature and extent of injuries caused by malpractice, the necessity of medical treatment to repair the harm caused by the malpractice, and the probable need for future treatment.

In addition, victims of medical malpractice must prove the reasonableness of medical expenses they incurred to treat the harm caused by medical malpractice. That proof often requires the testimony of an expert witness.

Example of Medical Expenses in a Medical Malpractice Case

Medical expenses associated with medical malpractice can be substantial. A 35-year-old woman in Texas was pregnant with her first child. She first saw a doctor in her ninth week of pregnancy. Her pregnancy was uneventful until a routine prenatal checkup in her 37th week revealed an elevated level of hemoglobin, a test result consistent with blood loss. That evening, she was admitted to a hospital with severe abdominal pain. An ultrasound revealed that her fetus had detached from the uterine wall.

Further tests revealed that the woman suffered from a blood clotting disorder. She was infused with blood products, including plasma, red blood cells, and platelets. After she delivered a stillborn baby, further tests revealed that her blood still was not clotting properly and that she was suffering from significant blood loss. She was transferred to ICU, where an EKG indicated that she had an elevated heart rate.

During her stay in the ICU, nurses noted a drop in blood pressure and abnormally low oxygen saturation. Tests revealed that her blood was not clotting at a normal rate and that her kidneys were not receiving adequate blood flow. Doctors concluded that the woman had developed uterine atony, a loss of muscle tone in the uterus that prevents it from contracting and clamping down, resulting in excessive blood loss. They performed a hysterectomy to remove the failing uterus and stop hemorrhaging. In the operating room, the woman’s heart stopped because of blood loss.

The woman survived the surgery but experienced post-surgical seizures. A neurologist determined that she suffered brain damage because of her brain had been deprived of oxygen when her heart stopped pumping and perhaps in the hours leading up to her heart failure. After months of rehabilitation, doctors agreed that she would remain in a persistent state of vegetation.

Reasonableness of Medical Bills

The woman’s husband sued various healthcare providers for malpractice. The jury returned a verdict of more than $10 million, including almost $704,000 for past medical expenses and more than $7.2 million for future medical expenses.

While Texas allows the reasonableness and necessity of medical bills to be established by affidavit, it also gives the opposing party the right to challenge those affidavits. On appeal, the court noted that the Texas legislature’s effort to streamline proof of reasonableness and necessity of medical expenses “cannot negate the requirement that reasonableness and necessity be in fact proven by legally sufficient evidence.”

The appellate court noted that the reasonableness of medical bills is not always apparent. The court stated that “costs today are complex, and the price of a particular provider’s services may depend on many factors, including geography, experience, location, government payment methods, and the desire to make a profit.”

The court also noted that “it is not uncommon or surprising that a given medical provider may have no basis for knowing what is a ‘reasonable’ fee for a specific service.” Doctors focus on medicine, not on the cost of providing medicine. They might know what they charge, but reasonable fees are based on usual and customary charges within a community. Most doctors are not acquainted with usual fees charged by comparable doctors for similar services. Doctors are therefore not in a position to provide the expert testimony needed to prove that medical bills are reasonable.

How Medical Billing Experts Prove Reasonableness

Since ordinary jurors do not know whether a particular charge for a medical service is reasonable, plaintiffs must typically present expert evidence to establish reasonableness. In some jurisdictions, the payment of a bill establishes a presumption of reasonableness, but defendants are entitled to challenge that presumption with expert evidence.

To form an opinion about the reasonableness of a medical billing, medical billing experts examine the Current Procedural Technology CPT codes in the billing to determine the services for which the patient was billed. They compare those codes to the medical records to determine the billing’s accuracy.

In some cases, medical billing experts find that doctors or hospitals billed for services and procedures that were never provided. They may also find that the patient was billed for a more complex or expensive procedure than the one that was performed. A careful review might find that the biller separated procedures that were performed at the same time and billed them as if they were performed at different times. All those billing errors inflate charges and render the billing unreasonable.

Medical billing experts then consult established databases to determine the fees charged by other physicians in the same community for the same services as those that were billed. The decide whether the fee that was charged falls within a range that is customarily charged in the same community for the same services by doctors of comparable skill and experience.

If the bill is accurate and if it falls within the range of fees charged by other physicians, the bill is reasonable. If the bill is inaccurate or if it is substantially higher than the fees charged by other physicians, it is likely unreasonable unless there is a credible explanation for the higher fee.

Medical billing review experts , unlike physicians, base their opinions on standardize methods that are accepted within their field of expertise and that produce reliable results. For that reason, judges routinely admit the opinion testimony of medical billing experts.

What Are Medical Billing and Medical Coding and Why Are they Important?

Mon, 20 Jun 2022 08:58:00 GMT

Healthcare consumers are often baffled by their medical bills. As long as an insurance company pays the bill, their attention is usually focused on whether the co-pay (if any) seems reasonable.

When consumers attempt to take a deeper dive into a medical bill, they tend to wonder why the bill is filled with numbers. Some numbers represent charges — the price for services that the provider is billing. But other numbers represent codes that drive the payments insurance companies make. To understand medical billing, it is important to examine the components of a bill and to learn how medical bills are prepared.

Components of a Medical Bill

Every medical bill includes the billing date and the patient’s account number. Patients need to provide their account number when they have questions about their bill so that the billing department match the bill to the patient. Billers need to be careful not to confuse account numbers. Mistakes can cause services to be billed to the wrong patient.

Other components of a medical bill usually appear in columns. Different providers may have different columns, but these basic components appear in nearly all medical bills:

1. The dates on which each billed service was provided is usually listed in a column on the left side of the bill.
2. A short description of the service provided or the supplies or medication that were dispensed to the patient. A description follows each date and is primarily for the patient’s benefit. Insurance companies are more interested in codes that follow the description.
3. A CPT code and a diagnostic code typically follow the written description. From an insurer’s perspective, the codes are the most important part of the bill. Codes are discussed in more detail below.
4. The fee charged for the service, procedure, supply, or medication. Some bills simply show the bottom-line charge the practice is billing to the patient or insurer. Other bills show a full charge and an adjustment representing a portion of the charge that the practice has agreed not to collect. Adjustments usually result from agreements with insurance companies about the dollar amount for a service that the practice will accept as full payment.
5. Payments received from insurance or the patient.
6. The unpaid balance that is the patient’s responsibility.

The amount due and the written description of services provided are usually of greatest concern to the patient. To an insurer (including government payers like Medicare and Medicaid), the codes typically determine whether the bill will be paid or denied.

Medical Bill Coding

Codes are inserted into a bill by medical billing coders . In some medical practices, the same person handles billing and coding. It is more common in larger practices for billers to handle the mechanics of preparing the bill, interacting with insurers, and answering billing questions posed by patients. A medical billing coder handles the more specialized task of assigning codes.

Coders assign two kinds of codes to medical bills. They base those codes on the patient’s medical records.

A diagnostic code is a numerical code used to identify a patient’s diagnosis. It describes the injury, disease, or health condition for which the patient received treatment. The World Health Organization (WHO) administers a system of diagnostic codes known as International Classification of Diseases (ICD).

Diagnostic codes are quite specific. For example, K40.01 is used to describe a bilateral inguinal hernia with obstruction, without gangrene, that is recurring. If the same hernia is not recurring, a different code would be assigned.

Current Procedural Terminology (CPT) codes are used to identify the specific service or procedure that a patient received. The American Medical Association (AMA) is responsible for creating and maintaining CPT codes. Coders must be familiar with thousands of codes and the rules that govern the choice of code.

Coders determine the CPT code by identifying each service or procedure that a patient received. Many different services may be reflected on a medical bill. For example, a patient might see a CPT code for an office visit, another CPT code for a blood test, and another CPT code for medication that was dispensed. Every time a coder identifies something that the patient received for which the patient should be charged, the coder must look up the corresponding CPT code and add it to the bill.

Why Codes Are Important

A CPT code should correspond to the written description of the service or procedure that was provided. However, different doctors might describe the same service in different ways. Insurance companies need to know exactly what service or procedure was provided so that the company can pay the fee it has agreed to pay for that service or procedure. Insurance companies rely on CPT codes rather than written description because the codes standardize descriptions of services and procedures.

Errors in the assignment of CPT codes can cause insurers to deny payment of the bill. Errors can also cause patients to be overcharged. For example, when a minor procedure is routinely performed as part of the major procedure, only the CPT code for the major procedure should be included in the bill. A CPT code for the minor procedure would be added only if the procedure was performed at a separate time. When the coder includes two CPT codes instead of one, the bill will be inflated. Either the patient will be overcharged or the insurer will deny payment. Either way, it is important for coders to get it right the first time.

Insurers look for a match between the diagnosis and the treatment provided. For example, suppose a patient is being treated for generalized pustular psoriasis. The diagnostic code is L40.01. But if the coder mistakenly inputs K40.01, the insurer will wonder why a patient with a hernia is being treated for psoriasis. The insurer will deny payment because the bill makes no sense.

Diagnostic and CPT codes may look like gibberish to patients. They are nevertheless the backbone of medical billing. Expert medical coders help doctors avoid billing errors by making sure that medical bills include the correct codes.

What Are Bundling and Unbundling in Medical Coding?

Mon, 13 Jun 2022 08:35:00 GMT

Medical coders assign 5-digit codes to each service or procedure that a medical practice provides to a patient. Those codes are used in billings. Insurance companies and the administrators of government programs (like Medicare and Medicaid) rely on the codes as a standardized description of the services and procedures for which the medical practice seeks payment.

The rules that govern the assignment of codes can be complex. That complexity becomes clear when procedures that have separate codes are performed together. Should they be billed as a single procedure or as two procedures? The question is one that coders must answer by relying on the rules that govern coding.

Whether procedures are performed separately or together might or might not determine the correct billing code. The choice to “bundle” or “unbundle” procedures affects the accuracy of medical bills. Making an incorrect choice is, in fact, one of the most common causes of billing errors.

Understanding CPT Codes

Medical billers work with (or share the duties of) medical coders. A coder assigns Current Procedural Terminology (CPT) codes to medical services and procedures. A basic CPT code is a five-digit code that describes the precise procedure or service that doctors provide to their patients. The codes were developed and are maintained by the American Medical Association (AMA).

Insurance companies and government agencies have agreed to pay a certain fee for each covered service or procedure identified by a CPT code. Using the correct CPT code is therefore essential to obtaining the correct payment for services and procedures. The AMA’s CPT codes are incorporated into the Healthcare Common Procedure Coding System (HCPCS) codes required for Medicare and Medicaid billing.

Medical billing coders review medical records, determine the service or procedure that the patient received, identify the CPT code that describes that service or procedure, and add the CPT code to the billing. Selecting the correct CPT code is vital to accurate billing. That can be a difficult task, as the AMA has created thousands of CPT codes.

Similar codes may be available to describe the same service or procedure, depending on a number of factors. A code may depend on the length of time it took to perform the service (such as an office visit). Other factors that affect code selection include the complexity of a procedure and whether a service was provided in person or by telehealth.

One of the key factors that applies to some multiple medical procedures is whether the procedures are customarily provided at the same time and whether they were provided to the billed patient at the same or different times. That factor is expressed in billing rules that govern bundling and unbundling of services.

Bundling in Medical Billings

Bundling refers to the use of a single CPT code to describe two separate procedures that were performed at the same time. Bundling rules typically require a healthcare provider to use the code for the more significant procedure when a minor procedure is performed at the same time.

As an obvious example, one CPT code describes the insertion of a needle into a vein. That code is used when the insertion is not part of another medical procedure. When a needle is inserted as part of a more complex procedure, only the CPT code for the more complex procedure should be used.

Diagnostic nasal endoscopies are another example. It is expected that a doctor will cauterize a nosebleed if the nosebleed is occurring during a nasal endoscopy. The CPT code should be used for the nasal endoscopy without adding a second CPT code that describes the cauterization of a nosebleed. However, if a doctor performs a nasal endoscopy and the patient returns later in the day with a nosebleed, it would be appropriate to bill for cauterizing the nosebleed since that procedure did not occur while the endoscopy was being performed. The coder would then add a modifier to the CPT code to make clear that the cauterization was a “distinct service.”

In some cases, there are three CPT codes to consider: two that describe each of two separate procedures and a third that describes the two procedures when they are performed together. The rationale for the third code is that it takes less total time to perform procedures together than to perform them at separate times. When the third code exists, it is the correct code when the procedures are performed together.

Coders should bundle services when CPT coding rules require them to do so. When services should not be bundled, however, a medical practice will lose revenue when a coder bundles them in error.

Unbundling in Medical Billings

Unbundling is the opposite of bundling. When two procedures should be bundled in a single CPT code, coders who bill the two procedures separately using two CPT codes are unbundling the procedures. Unbundling also occurs when a coder charges for two services when the code for the major service assumes that the minor service is also provided. Since two charges will result in a larger bill than a single comprehensive charge, unbundling results in overbilling.

Inflated billing may be caused by a coder who does not understand the CPT coding system or by a coder who was careless. When unbundling is a frequent billing error, the medical provider may have instructed the coder to unbundle as a way to increase revenue. Repeated unbundling can be a red flag for fraud investigators.

When a party needs to prove that a medical bill was reasonable to obtain reimbursement for the bill in litigation, unbundling can be evidence that the bill is excessive. Unbundled charges will generally need to be bundled to produce a reasonable bill.

Medical billing experts search for instances of unbundling in medical billings. By comparing medical records to medical billings, a medical billing expert can determine whether separately coded procedures were performed at the same time. A careful comparison can uncover unbundling errors that result in inflated billing.

Medical billing experts also help lawyers by identifying unreasonable and fraudulent billings. Unbundling is one of many issues that a medical billing expert might discover after a careful screening of medical bills.

How Can Working with a Medical Bill Advocate Benefit Your Law Firm?

Mon, 06 Jun 2022 08:40:00 GMT

Medical billing advocates help individuals who are being overcharged for medical services. They also help individuals in disputes with insurance companies. Law firms use medical billing advocates as expert witnesses in bad faith litigation against health insurance companies that deny payment of medical bills and to assist negotiations with health care providers who have sued the firm’s client for nonpayment of a medical bill.

What Do Medical Billing Advocates Do?

Medical billing advocates assist clients who believe they are being overcharged by healthcare providers or whose medical bills have not been paid by health insurance. Medical billing advocates help resolve disputes about the charges that patients owe and the denial of payment by health insurers.

Medical billing advocates scrutinize medical bills for errors. Those errors arise in many ways, including:

1. Billing for services that were never provided. A comparison of medical records to medical billings can reveal charges for services or products (such as medications) that a patient did not receive. This error often happens because a biller confuses one patient with another and charges the wrong patient for services. It can also result from a biller’s failure to review medical records thoroughly. For example, a biller might charge for a medication that a physician prescribed without verifying that the medication was dispensed.

2. Duplicate billing. Billers might mistakenly include multiple billings for a service that was provided only once. Duplicate billing is usually a clerical error. While it might occur innocently, the error inflates medical bills.

3. Using an incorrect CPT code. Medical bills are based on Current Procedural Terminology (CPT) codes that are assigned to each medical service or procedure. Thousands of CPT codes have been developed by the American Medical Association. Using the wrong CPT code can result in payment denials by insurers and in overcharges by hospitals, physicians, and other providers.

4. Using an incorrect diagnostic code . Medical billers review medical records to determine the health condition that was treated. That condition is described on medical bills by an International Classification of Diseases (ICD) code. When a biller uses an incorrect ICD code, it may not match the treatment reflected in the billing. A disconnect between ICD codes and CPT codes can cause insurers to deny payment of bills.

5. Unbundling services . When physicians perform two services or procedures at the same time, there is often a comprehensive CPT code that includes both procedures, particularly when they are commonly performed together. The charge associated with that code is less than the charges for the CPT codes that describe the separate procedures because it takes a physician less total time to perform the procedures together than to perform each one at separate times. Medical billers improperly “unbundle” charges when they use separate CPT codes for the procedures rather than the single, comprehensive code that describes both procedures. Unbundling results in overbilling.

Billing errors are usually caused by billers or coders who, because of inattention or poor training, make honest mistakes. On occasion, billers and coders are instructed to engage in fraudulent billing to deliberately inflate the profits of a medical practice.

Medical billing advocates detect billing errors and bring them to the attention of the patient or lawyer who hired them. That information can be used to reduce billings, to resolve payment disputes, and to support appeals from health insurance claim denials. Medical billing reviews can also support other kinds of litigation.

Health Insurance Claim Denials

Health insurers are not always transparent about their reasons for denying payment of a billing. Medical billing advocates can identify the precise reason why payment was denied and can help clients correct the problem so that the bill can be paid, at least in part. Changing a diagnostic code and resubmitting the bill, for example, may result in bill payment, provided the diagnostic code is consistent with the condition that the provider treated and with the treatment that was billed.

In some cases, health insurers legitimately decline payment of bills because the billing is excessive. Duplicate billing, unbundling, and using a CPT code that describes a more expensive procedure than the one provided are examples of errors that lead to legitimate claim denials. In those cases, a medical billing advocate can provide information that persuades the provider to reduce the bill, saving the patient from being billed for the portion that insurance does not cover.

Not all denials of health insurance claims can be resolved successfully. If a health insurance plan might not cover a billed procedure or if a patient failed to obtain required pre-authorization for a nonemergency procedure, the insurer might legitimately to deny the claim. However, when denials are based the insurer’s failure to understand the billing or on correctable billing errors, a medical billing advocate can help patients and their lawyers prevail in appeals from claim denials.

How Medical Billing Advocates Help Lawyers

In addition to helping lawyers pursue appeals from health insurance claim denials, medical billing advocates can provide evidence to support bad faith claims against insurers. An insurer that has no reasonable basis for denying payment may be liable for the tort of bad faith. Lawyers can decide whether the policy language provides a reasonable basis for denying the claim, while medical billing advocates can provide expert testimony about the bill’s reasonableness and compliance with billing standards.

Medical billing experts help lawyers in other contexts. When lawyers defend collection actions that hospitals and medical practices bring against their clients, a medical billing advocate can offer evidence of overbilling. Responding to collection letters with a medical billing advocate’s review of inflated billings can lead to the negotiation of a reduced billing and a favorable payment plan. Many providers become more reasonable in their collection efforts when they realize that might face testimony in court about overbilling a patient.

In personal injury litigation, medical billing experts provide testimony to prove or challenge the reasonableness of medical bills for which a plaintiff seeks reimbursement. In False Claims Act litigation, medical billing experts can provide expert evidence that medical billings submitted to Medicare or Medicaid were fraudulent. Any time the fairness and accuracy of a medical bill is an issue in a case, a medical billing advocate can help lawyers analyze the bill’s legitimacy.

Understanding Unbundling in Medical Billing

Mon, 30 May 2022 10:15:00 GMT

Medical bills can be inaccurate for many reasons. Sometimes coders make mistakes when they prepare medical bills. Sometimes medical practices deliberately make coding decisions that result in overbilling. One of the coding issues that leads to overbilling is known as unbundling.

Unbundling can affect the reasonableness of medical charges. Personal injury claims that require the proof of reasonableness may be undermined by expert testimony that points to unbundling as the cause of unreasonable billing.

Unbundling might also be exposed by whistleblowers. Medical billing experts support whistleblowing lawsuits against providers who overbill Medicare and other government insurers by providing expert testimony about unbundling that they detect in healthcare bills.

CPT Codes

An understanding of unbundling begins with an understanding of how medical bills are coded. Medical billings are created by billing specialists who rely on codes developed by the American Medical Association . The AMA has assigned a five-digit code to each procedure or service that doctors provide to their patients. These Current Procedural Terminology (CPT) codes are the backbone of modern billing systems.

Insurance companies rely on CPT codes as a means of standardizing the descriptions of procedures and services for which physicians and medical practices seek reimbursement. Medicare and Medicaid bills must follow the Healthcare Common Procedure Coding System (HCPCS), which incorporates the AMA’s CPT codes.

Medical practices employ or hire medical billing coders to translate medical records into CPT codes for billings. A medical coder reviews the medical records, determines the precise service or procedure that the patient received, identifies the CPT code that describes that service or procedure, and includes the CPT in the billing. The insurance company or Medicare/Medicaid then reimburses the amount they have agreed to pay for services and procedures described by each billed CPT code.

Selecting the correct CPT code is vital to accurate billing. That can be a formidable task, as the AMA has created thousands of CPT codes. Several different codes may be available to describe the same service or procedure, depending on (for example) the amount of time involved, the complexity of the procedure, how it is performed, or whether a service was provided in person or by telehealth.

Ideally, coders have extensive training and experience, making them adept at understanding medical records and identifying the correct CPT code to describe the services or procedures that are documented in those records. Coders have typically studied medical terminology, anatomy, pathology, and other aspects of medical science, in addition to learning the nuances of the CPT coding system.

Bundling in Medical Billings

In some cases, procedures described by different CPT codes are provided at the same time. For example, a surgeon might perform a procedure described by a CPT code as “Repair of double outlet right ventricle with intraventricular tunnel repair.” At the same time, the surgeon might perform a procedure described as “repair of right ventricular outflow tract obstruction.” Rather than billing those two procedures as separate procedures, they should be bundled by using the single CPT code that describes both procedures.

In other cases, performing a minor procedure is an expected component of a major procedure. For example, it is common to cauterize a nosebleed while performing a diagnostic nasal endoscopy. While there is a CPT code for cauterizing nosebleeds, it should not be used when that procedure is encompassed by the more complex endoscopy. Rather, the procedure should be billed using just the CPT code for the endoscopy.

Coders need to determine when bundling is required and when it is not. Bundling procedures that should be billed with separate CPT codes can cause a practice to lose revenue. Whether procedures should be bundled typically depends on whether they were performed at the same time. Bundling recognizes that procedures provided at the same time take less total time than procedures provided as different times.

In the endoscopy example, suppose the patient leaves the clinic after the endoscopy is finished but returns later in the day with a nosebleed. If the physician cauterizes the nosebleed, it is appropriate to bill the endoscopy and the cauterization using separate CPT codes because they were provided at different times. The coder would then add a modifier (59, signifying a “distinct service”) to indicate that the two procedures were performed separately and that reimbursement for both is appropriate.

Unbundling in Medical Billings

Unbundling is the flip side of bundling. When two procedures are provided at the same time and the two procedures are described by a single comprehensive CPT code, billers are overcharging the patient (and the insurer) by billing the two procedures separately using two CPT codes.

Overbilling also occurs when a coder charges for two services when the code for the major service assumes that the minor service is also provided. For example, the code for a cardiovascular stress test assumes that the physician administered an ECG during the test. If the billing includes a code for a cardiovascular stress test and a separate billing for an ECG, the billing is excessive.

Unbundling inflates billings. Excessive billing may be caused by a coder who does not understand the CPT coding system or did not take the time to determine the correct codes. Unbundling can also be a deliberate strategy to charge more than a health care provider is entitled to receive for the billed procedures. An occasional bundling error might lead to denied payments, or to payments that are delayed until the error is corrected. A series of unbunding errors over time may lead to a fraud investigation, particularly when bills are submitted for payment by Medicare or Medicaid.

Medical billing experts search for instances of unbundling in medical billings . By comparing medical records to medical billings, a medical billing expert can determine whether separately coded procedures were performed at the same time. A careful comparison can uncover unbundling errors that result in inflated billing.

Medical billing experts help lawyers by identifying unreasonable and fraudulent billings. Unbundling is one of many issues that a medical billing expert might discover after a careful screening of medical bills.

Are You Struggling to Find the Best Medical Billing Company?

Mon, 23 May 2022 10:13:00 GMT

The medical billing outsourcing industry has grown at a steady rate in recent years. Industry analysts project a 12.6% annual increase in medical billing outsourcing each year until 2028. Medical practices are moving to outsourcing as their billing systems become obsolete. Maintaining a trained billing and coding staff adds to medical practice overhead. Doctors who administer a billing department are taking time away from providing medical services. Revenues suffer when doctors focus on oversight of billing staff and resolving billing issues instead of providing billable medical services to patients.

An effective medical billing staff must keep up with changes in Current Procedural Terminology ( CPT Codes ) and International Classification of Diseases (ICD) codes. Most medical practices do not have a sufficiently large billing staff to justify the expense of in-house training. They must fund continuing education programs that take staff members out of the office. Practices that do not assure that billers and coders have up-to-date training take the risk that staff members will make errors that cause payments to be delayed or denied.

Outsourcing billing helps a medical practice focus on what it does best: serving patients. Outsourcing reduces overhead, minimizes billing errors, and improves cash flow. It isn’t surprising that medical practices are increasingly outsourcing their billing.

As the medical billing outsourcing industry grows, new companies are competing for business. Competition is a valuable means of assuring that practices pay reasonable fees for the services they outsource. At the same time, competition creates a confusing array of choices for medical practices as they search for the right medical billing provider. Here are some important factors that medical practices should consider when they select a medical billing company .

Look For a Company That Matches Your Practice’s Size and Specialty

A billing company that is geared to handle billing for hospitals and large practices with multiple branches might not be the best choice for a practice that employs only a few physicians or that limits its practice area to a particular specialty. It will often become immediately apparent that a particular billing company is not a good “fit” for the practice’s needs.

A medical practice should tell medical billing companies the size of their practice, both in terms of physicians who provide billed services and the dollar volume of billings each year. Practices should look for billing companies that are accustomed to servicing healthcare firms that are similar to their own. The practice should also estimate the cost of its in-house billing services and suggest a smaller amount as the budget it is prepared to pay.

The nature of a medical practice may be another important factor. Most billing companies serve clients who provide a typical range of medical services to patients. They might be less comfortable serving a specialized practice. For example, a medical practice that focuses on mental health care will require coders to be familiar with CPT codes that are unique to that specialty. It is wise to ask about the billing company’s experience with practices in similar fields of medicine.

A practice should identify the insurers that it most frequently bills. Choosing a billing company that has established a working relationship with those insurers will smooth the transition from in-house to outsourced billing.

Identify the Services that a Biller Is Providing

Do the billing company’s services consist only of preparing and submitting bills? What does it do when payment is denied? Some billing companies do nothing. Others identify the issue that caused the denial and work to correct the problem. If a billing company isn’t resubmitting denied claims when there is a basis for doing so, the company is costing the medical practice revenue.

Ask for a Projection of Costs of Services Provided

Medical billing companies bill in a variety of ways. Charging a percentage of net collections is common, but the percentage can vary considerably. Make sure you understand the percentage that will apply to your practice and how the biller’s fee will be calculated. Compare price structures of different billing companies to get a sense of whether a company’s cost projections are reasonable.

Other companies may charge a flat fee. Some charge a flat fee plus a small percentage of collections. A medical practice might want to have its accountant do a ballpark estimate of the fees that the practice will pay under different payment methods.

Determine Software Compatibility

One of the key issues when outsourcing billing is how the biller’s software will interface with the medical practice’s software. The trend is for medical practices to keep medical records online. The billing company will need to access those records to generate billings. The company will also need to access to patient information that may be kept in a separate program.

If a billing company cannot interface with your existing software, it may demand that your practice change its software to accommodate the biller’s needs. That change can be time consuming. Staff members will need to learn the new software and will need to spend time integrating data from the previous software. Any change in data processing is likely to lead to errors that will need to be corrected later.

If a software change is inevitable, ask the billing company whether it will train your staff to use the new software. Some companies provide free training, others train for a fee, and some offer no training at all.

Ask About Compliance

Complying with rules and regulations governing patient confidentiality and billing procedures is essential to a healthy medical practice. A biller’s breach of the rules can expose the practice to liability. Ask for an outline of the company’s compliance procedures and the steps the company takes to assure that their employees follow them.

Research Billing Companies

Similar medical practices that have transitioned successfully to outsourced medical billing may be willing to discuss the pros and cons of the company they hired. Online reviews should always be taken with a grain of salt, but a series of negative reviews about responsiveness or billing errors should be a red flag.

What Is the Reasonable Value of Medical Charges in a Personal Injury Case?

Mon, 16 May 2022 10:21:00 GMT

State law governs the recovery of damages in personal injury cases. Every state allows injury victims to recover necessary and reasonable medical expenses that were incurred because of another person’s negligence. The necessity of treatment is proved by medical testimony.

The reasonable value of medical expenses is generally the usual and customary charge for the billed service or procedure. How that reasonable value is determined depends on state law. Medical billing experts help lawyers prove and challenge the reasonable value of medical services.

Presumption of Reasonableness

Some (but not all) states presume that medical expenses are reasonable when the patient, a health insurer, or someone else paid the bill. The theory underlying the presumption is that nobody would pay an unreasonable bill.

The presumption of reasonableness does not attach to any portion of the bill that was not paid. Health insurance companies often pay only a portion of a bill for medical services. Even when the provider agrees to accept partial payment as full payment, most states rely on the collateral source rule to give injury victims the opportunity to collect the entire bill. However, injury victims cannot rely on the presumption of reasonableness to establish that unpaid charges are reasonable.

Defendants are allowed to rebut the presumption of reasonableness. If a defendant can establish that a health insurer paid an unreasonable charge, the defendant will not he liable for that charge.

UCR Charges

The UCR (usual, customary, and reasonable) amount of a medical bill is generally defined by two factors. The “usual” charge is the charge that the same provider ordinarily bills to other patients for the same procedure or service. If a health care provider inflates a charge without justification in a particular case, the inflated charge is not the usual charge.

The customary charge is the charge that other providers in the same geographic area bill for the same services. The geographic limitation recognizes that the usual charge for a service in Clearwater, Florida will not necessarily be the same as the charge billed for the same service in New York City.

A range of charges may fall within the definition of customary charges. Some doctors charge more for a procedure because they more experience and skill or a better reputation than other doctors. Some charge less because they have not altered their fee schedules in recent years. The mean or average charge will typically be a reasonable charge, but charges that are higher than the average may also be reasonable if they fall within a reasonable range. Charges that are well above the average might not be reasonable.

Opinions About Reasonableness and Daubert

Medical billing experts provide opinions about the reasonable value of medical billings. Those opinions are routinely admitted into evidence in state and federal courts.

Doctors are not usually qualified to give an opinion about the reasonableness of their own charges. They might have anecdotal information about the charges of other practitioners in the same area for the same services, but they have rarely gathered sufficient facts to support an opinion about the usual, customary, and reasonable charges that prevail in their geographic area. Nor have they used a reasonable methodology to form their opinion.

Courts recognize that medical billing experts are qualified to render expert opinions by virtue of training and experience that most people lack. Medical billing experts learn to understand billing standards and the complex procedural codes that identify the specific services and procedures that have been billed. Courts agree that medical billing experts do not need medical training to qualify as expert witnesses in medical billing, but billing experts do acquire specialized knowledge that allows them to understand medical records and interpret diagnostic and procedural codes.

To satisfy the Daubert standard, medical billing experts base their opinions on sufficient facts and data. They rely on medical records and on databases that supply the costs of specific medical services that other providers within the same zip code have billed for the same services. Those sources provide sufficient data to support an expert’s analysis of a medical billing.

Expert Methodology to Determine Reasonable Value

After gathering data, medical billing experts derive their opinions from reliable methodologies. They begin by performing a line-by-line analysis of medical bills. They look for errors, including duplicate charges and other data entry errors.

After scrutinizing the billing, medical billing experts compare billings to medical records. Medical billings use procedural codes to identify services and procedures provided to a patient. Billing experts determine whether the medical records indicate that the services and procedures identified by procedural codes are the services and procedures that were provided.

Medical billing experts rely on their expert understanding of billing codes to assure that the billing does not reflect a more expensive service than the service that the patient received. For example, a billing code might reflect a more complex procedure than the one that was performed. An error of that nature results in overbilling. Overbilling always results in unreasonable charges.

Medical billing experts search billings for “ unbundling ” errors that occur when doctors use billing codes for separate services that were provided at the same time. Billing experts are aware of coding rules that require billers to use a single code, rather than multiple codes, to reflect certain procedures that are commonly undertaken in a single session. Using separate codes to describe the separate sessions result in overbilling.

Finally, medical billing experts use reliable databases to determine the actual prices charged by other physicians in the same area for the same services. That analysis allows the expert to determine whether the medical billing falls within a reasonable range of charges for the same services or is substantially higher. Billing databases are widely accepted as a reliable source of facts and data that supports a billing expert’s opinion regarding the reasonableness of medical billings

In personal injury cases, both plaintiffs and defendants can benefit from a medical billing expert’s analysis of the reasonable value of billed services. Plaintiffs use medical billing experts to prove reasonableness as a condition of recovering reimbursement of those charges as damages. Conversely, defendants use medical billing experts to challenge unreasonable charges.

What Are the 7 Reasons to Outsource Medical Billing?

Mon, 09 May 2022 09:56:00 GMT

Medical billing provides the revenue that keeps a medical practice alive. Like blood flowing through a patient’s body, a healthy revenue flow is essential to the health of a medical practice. When billings fail to generate revenue, a medical practice must borrow money to pay its own bills. Debt can eventually cripple a business.

Some practices have a team of individuals in a billing department who are responsible for preparing billings and interfacing with patients, insurance companies, Medicare, and other payers for medical services. That team might consist of billers and coders or both functions might be combined. A practice manager will generally oversee the billing department while the practice owners oversee the manager. That arrangement might work for some medical practices, but it is not always the most efficient use of professional resources.

The alternative is to outsource medical billing . The growth of the medical billing outsourcing market in recent years reflects the transition from obsolete in-house billing systems to reliance on specialized firms that free doctors from the burden of managing their own billings. Here are 7 reasons why outsourcing is often the preferred means of safeguarding revenues.

1. Medical Billing Companies Have State-of-the-Art Billing Systems

Billing software is expensive. Practices that invested in billing software just five years ago are now realizing that their software is outdated and may need to be replaced. Yet new software acquisition imposes new costs on the practice, including the expense of integrating old billing records with new billings and training a billing team to learn how to use the software.

More than a dozen companies market software packages to prepare medical billings and track receivables. Which software is the best? Doctors are trained in medicine, not accounting or internet technology. Medical billing companies do thorough studies of alternative software packages and constantly evaluate the need to upgrade. A medical practice that outsources billing will be relieved of the challenge of purchasing and upgrading billing software and training staff to use it.

2. Medical Billing Companies Keep Abreast of Changes in Coding

An important key to securing prompt payment by insurance companies is the accurate coding of medical billings. Both diagnostic codes and current procedural technology (CPT) codes must be consistent with current standards. Yet the AMA regularly adds new CPT codes, making it difficult for medical practices to stay abreast of the current coding system. Medicare’s HCPCS coding system incorporates CPT codes, making it essential for Medicare service providers to assure that billings reflect accurate codes.

Medical practices that bill in-house generally incur the expense of sending coders to seminars and continuing education programs to learn about changes in CPT codes and to keep their skills fresh. Training costs reduce profits. There is also a risk that new codes will be in effect for months before billing and coding staff learn about them. Medical billing companies provides constant training to their coders, assuring that they have the up-to-the-minute knowledge needed to prepare accurate bills.

3. Medical Billing Companies Reduce Billing Errors

Doctors who specialize in a field of medicine become adept at diagnosing and treating patients within their specialty. Medical billing companies offer the same quality of service that results from specialization. They develop the skills necessary to understand medical records, to derive the correct diagnostic codes from those records, and to assign each service or procedure to its correct CPT code.

When medical practices hire new staff for billing departments, they endure a learning curve during which errors are more prevalent. When medical billing companies hire new staff, experienced supervisors review their work to assure that they produce an error-free billing. Employee turnover has no impact on a medical practice that outsources its billings.

4. Medical Billing Companies Improve Cash Flow

Medical practices do not get paid unless they generate accurate medical bills that satisfy insurance and Medicare billing standards. Inaccurate bills result in denials of payment. Correcting the error or appealing a denial may eventually result in payment, but every payment delay puts a strain on cash flow. Medical billing companies improve the likelihood that the medical practice will get the bill right the first time. Improved billing accuracy increases the likelihood that medical practices will receive the revenues they anticipate in a timely fashion.

In addition, in-house billing departments tend to be relatively small. When a biller or coder takes a vacation or an unexpected leave of absence, or when one quits and needs to be replaced, billing may be disrupted. Any delay in submitting bills and addressing billing inquiries delays receipt of revenues. Hiring a medical billing company improves cash flow by guaranteeing that billing duties will be performed on time.

5. Medical Billing Companies Reduce Practice Overhead

Maintaining a medical billing department requires a practice to hire staff members, to pay their salaries and benefits, to incur the cost of continuing education in medical coding, and to add to the overhead expense of unemployment insurance and workers’ compensation. In addition, every employee creates a risk that a medical practice will be accused of violating employment laws regarding wage payments, discrimination, hostile work environments, denials of mandated leave, and other worker protections.

Outsourcing billing eliminates the overhead and administrative burdens of employing workers to perform services that are collateral to the delivery of medical care. Any reduction of employees who do not deliver care is beneficial to a medical practice’s bottom line.

6. Medical Billing Companies Allow Doctors to Focus on Practicing Medicine

Maintaining a billing department adds to the administrative burdens of doctors. Hiring, supervising, disciplining, and terminating billing staff takes time away from the professional duties that generate income — spending time with patients and providing quality care.

7. Medical Billing Companies Improve Regulatory Compliance

State and federal regulations, as well as mandates imposed by insurance companies and the Centers for Medicare and Medicaid Services, are always changing. Expecting a billing department to keep up with regulatory changes may be an invitation to disaster.

Medical billing companies routinely obtain legal advice to assure that their billing standards comply with all regulatory requirements. Because billing companies serve a variety of medical practices, they can assure regulatory compliance more cost effectively that individual practices with relatively small billing departments. Billing companies are therefore able to stay on top of billing protocols and to produce billings that will satisfy payers and regulators.

Avoiding Errors in Mental Health Billing

Mon, 02 May 2022 13:42:00 GMT

Medical billing is the process of submitting charges for medical services to a patient and the patient’s insurer for payment. Since most billings are paid by insurers, billings need to meet industry standards by providing sufficient detail to allow the insurer to verify that the charges are accurate and reasonable.

Medical bills are usually prepared by specialists who review medical records and translate services and procedures into standardized codes that insurance companies recognize. Insurers base payments on the codes. The process of coding can be complex, but medical coders are trained to determine the precise code that describes each procedure or service rendered.

Coding can be even more complex when a patient receives mental health services. While services and procedures that treat physical illnesses and injuries are reasonably standardized, mental health providers are less uniform in treatment approaches. How to label a particular treatment approach may be a matter of opinion. Labels matter less than codes when it comes to being paid, but the selection of a code can lead to billing disputes that cause payments to be delayed or denied.

Codes are also important because an insurance company might cover some mental health services but not others. Using the wrong code and resubmitting the bill with a different code can make an insurance company suspect that it is being billed for a service its policy does not cover. Getting it right the first time maximizes the provider’s opportunity to be paid.

Billers and coders can help a mental health care provider’s cash flow by avoiding errors that delay payment. Here are some of the errors that are most common to mental health billing.

Billing for Excessive Visits

Practitioners want to bill for the work they actually perform, but before they provide services, they should be aware of what insurance will or will not cover. Providers take the risk that patients might not pay bills that insurance does not cover. Billers can help practitioners by recognizing the limits of coverage.

For example, insurers will not typically pay for unlimited visits with a patient. One or two visits per week are fairly standard. An insurer that sees a bill for daily visits might question whether the therapist is billing for reasonable and necessary services.

When a therapist bills for visits with an excessive number of patients during the day, the therapist may be inviting accusations of fraud. Billing for two dozen 45-minute psychotherapy sessions in the same day using the same billing code is an invitation to a billing audit.

Billing Incorrect Time Units

Closely related to billing for visits that didn’t occur is the problem of billing for longer visits than those that occurred. For example, a psychotherapy session that lasts between 38 and 52 minutes should be billed using the code for a 45-minute session. Rounding up to the code for a 60-minute session will result in excessive billing. An audit will result in claim denials and could trigger a fraud investigation.

Using the Wrong ICD Code

Coders identify the mental health provider’s diagnosis with an International Classification of Diseases (ICD) code. Different patients may be diagnosed with a variety of different mental health conditions. Unless a provider’s practice is very specialized, a provider may treat a patient for an anxiety disorder, treat the next patient for post-traumatic stress disorder, treat the next patient for depression, and so on.

A coder who assigns the same ICD code to each patient billing is doing a disservice to the provider. The failure to use the correct ICD code may be a red flag that triggers a billing audit.

Coders should never be lazy. They should review the medical record thoroughly to understand the provider’s diagnosis. They should then select the ICD code that most closely matches the condition or conditions that the provider describes in the medial records.

Using the Wrong CPT Code

Current procedural terminology (CPT) codes describe the specific mental health services provided. Different codes may describe similar services. For example, in-person psychotherapy sessions and telehealth psychotherapy sessions are described by different codes. Family psychotherapy sessions and non-family group psychotherapy sessions are also described by different codes.

Errors in the assignment of a CPT code can delay the payment of bills. Errors can also result in overbilling or underbilling. While underbilling costs practice money, overbilling associated with upcoding (using a CPT code for a more expensive service than the one that was provided) can lead to audits and fraud investigations. Identifying and using the correct CPT code is essential to accurate mental health billing.

Insufficient Documentation

Insurers, including Medicare and Medicaid, will deny claims that are not supported by adequate documentation. While creating documentation is the provider’s responsibility, billers and coders should recognize that necessary documentation is missing when they review the patient’s chart to prepare a bill.

Inadequate documentation can lead to downcoding. If the documentation does not support a one-hour psychotherapy visit, the insurer may downcode the visit to a 30-minute visit, the shortest visit supported by a CPT code. An appeal from a downcoding may or may not be successful, but the need to appeal means that payment will be delayed and cash flow disrupted.

Documentation errors may include missing notes, insufficient orders, lack of care plans, missing time sheets, and a failure to establish that billed services were actually provided. A biller who flags a problem with documentation can avoid claim denials by asking the provider to correct it.

Billing for Non-Covered Services

Private insurers cover only the mental health services described in a health insurance policy. They might only cover services that they are legally required to cover or they might cover more expansive services. Billing an insurer for uncovered services will result in a claim denial.

Medicare generally covers psychotherapy, diagnostic testing, an annual depression screening, certain medications, and a variety of other forms of therapy (such as electroconvulsive therapy and hypnotherapy). Medicare does not generally cover marriage or pastoral counseling, biofeedback training, adult day health programs, and certain other mental health services.

Providers should be aware of coverage limitations before they decide to provide services. Trying to disguise noncovered services as covered services can be prosecuted as fraud and may jeopardize a provider’s ability to provide Medicare-covered services in the future.

Does Attorney-Client Privilege Cover Communications with Medical Billing Experts?

Mon, 25 Apr 2022 12:19:00 GMT

Lawyers hire medical billing experts for many reasons. They are an important link in the chain of evidence to recover (or defend against) medical expenses in personal injury cases. Most jurisdictions only allow the recovery of “reasonable” medical expenses. Medical billing experts are uniquely qualified to provide expert testimony about the reasonableness of medical bills.

Medical billing experts also testify in insurance disputes and in false claims lawsuits. Any litigation that asks whether a healthcare provider overbilled will benefit from the testimony of a medical billing expert.

The communications between lawyers and their clients are privileged from discovery. In other words, clients who testify in court or in depositions are not required to disclose what they have been told by their attorneys.

Does that same privilege extend to communications between lawyers and the medical billing experts they have hired for their client’s litigation? The answer depends on the circumstances.

Testifying and Consulting Experts

Experts can be retained for different purposes in litigation. Consulting experts provide information to an attorney that the attorney needs to prepare for trial. Consulting experts are not expected to testify as witnesses. They are not required to prepare reports that comply with the requirements that rules of evidence impose upon testifying experts. They usually offer informal opinions that are often communicated in emails or in conversation.

Testifying experts are retained for the purpose of giving evidence. A testifying expert must usually prepare a report that complies with the applicable rules of procedure. In federal court, the rules require the report to disclose specific detailed opinion about the expert, the expert’s compensation, the expert’s precise opinions, the facts upon which the expert relied, and the reasoning that supports the expert’s opinions.

In some cases, consulting experts become testifying experts. For example, a lawyer might initially retain a medical billing expert to determine whether medical expenses are reasonable. If the expert’s opinion favors the lawyer’s client, the lawyer may decide to hire the expert to testify in court. If the expert’s opinion does not favor the client, the lawyer may decide not to pursue that aspect of a claim or defense.

Testifying Medical Billing Experts

The Federal Rules of Civil Procedure (and typically their state counterparts) require lawyers to disclose the identities of experts who have been retained to offer evidence in a case. Lawyers must also disclose the expert’s formal report to opposing counsel.

While the formal report must be disclosed, prior drafts of the report are usually protected from disclosure. It is not unusual for a report to evolve over time. Nor is it unusual for experts to share reports with the lawyer who retained them and to prepare a new draft after the lawyer identifies weaknesses in the expert’s data or reasoning. Under most circumstances, those earlier drafts of the report cannot be discovered by the opposing party.

The exception for prior drafts is narrow. An expert’s notes, for example, might not be regarded as the prior draft of a report. Courts also allow discovery of prior drafts when the opposing party has a substantial need for the report.

Even before the report is prepared, the lawyer and the expert will probably communicate about the nature of the expert opinions that the lawyer requires. The lawyer will generally share documents and provide facts that the expert will rely upon to form an opinion. In the case of a medical billing expert, for example, the lawyer will at least provide medical billings and medical records for the expert to review.

The Federal Rules of Civil Procedure protect some, but not all, communications between a lawyer and a testifying expert. When the communication is protected, the form of the communication — letter, email, or conversation — does not matter. Protected communications need not be disclosed in discovery.

Communications of the lawyer’s mental impressions about the case and the lawyer’s legal theories are at the heart of the rule protecting communications with lawyers from disclosure. Communications between an expert and the lawyer’s client, however, enjoy no protection.

Exceptions to the rule that protects attorney communications with experts from discovery include:

The phrase “facts or data” includes anything the expert considered in forming an opinion, even if the expert ultimately chose not to rely upon it. For example, a billing expert might consider prices charged by other doctors for similar procedures when the expert considers whether charges are reasonable. The expert might decide that certain doctors are less experienced or are otherwise not suitable for comparison. The fact that the expert considered but rejected certain data for comparative purposes makes the data discoverable.

Consulting Medical Billing Experts

Testifying experts are subject to discovery, including discovery of certain communications with the lawyers who retain them, because they will be offering opinions at trial. Consulting experts who do not testify are subject to different rules.

For the most part, opinions communicated to a lawyer by a consulting expert are protected from discovery. That protection includes facts communicated to the expert by the lawyer. A medical billing expert who reviews data and provides opinions to a lawyer but who is not expected to testify at trial is generally shielded from discovery.

A narrow exception to that rule applies when exceptional circumstances exist that make it impracticable for the opposing party to obtain facts or opinions on the same subject by other means. That exception rarely applies to medical billing experts because there are almost always other sources of facts and opinions available to opposing parties.

How Does Medical Coding Differ from Medical Billing?

Mon, 11 Apr 2022 06:50:00 GMT

Every private medical practice bills patients for their services. Billings are usually submitted directly to the patient’s insurance company or to a government insurer, such as Medicare or Medicaid. Government insurers and most private insurers require billings to be annotated with codes that specify the exact service or procedure that is being billed. Codes are therefore a vital part of medical billing, but medical billing involves more than assembling a collection of codes.

Medical billing and medical coding are two different functions that are often performed by two different groups of employees. Some providers handle all of their billing and coding internally while others outsource both functions. Some handle one function internally but outsource the other.

Since billing and coding require different skill sets, it is common for different individuals to perform the two functions. Medical billing experts have knowledge of both coding and billing practices.

Medical Coding

Medical coding is the process of translating services and procedures described in medical records into standardized codes. The two sets of codes that are commonly used are diagnostic (ICD) codes and procedural (CPT) codes. Medicare and Medicaid billings incorporate CPT codes in a more expansive HCPCS coding system.

Diagnostic codes describe medical conditions. The International Statistical Classification of Diseases and Related Health Problems (ICD) codes are a list of medical classifications created by the World Health Organization. The current list in widespread use has been designated ICD-10-CM.

Coders determine the correct ICD code by reviewing medical records and determining the specific health condition diagnosed by a healthcare provider. For example, a gastric ulcer that has not been designated as acute or chronic and that has not shown evidence of a hemorrhage or perforation would be coded as K25.9.

While ICD codes are used for statistical and research purposes, they also help insurers understand why a patient obtained treatment. When an insurer is billed for treatment of a gastric ulcer, an insurer will expect the billing to show an ICD code that reflects a diagnosis of that condition. If there is a disconnect between the diagnosis and the treatment, the insurer may reject the billing.

Procedural codes describe services and procedures that were rendered by a healthcare provider. Current Procedural Terminology (CPT) codes are developed, maintained, and regularly updated by the American Medical Association, often with input from insurers and the Centers for Medicare and Medicaid Services.

Coders determine the correct CPT code by reviewing medical records and identifying each service or procedure that a patient received. They match each procedure or service to a 5-digit code. In some cases, they may attach an additional code (known as a modifier) to provide extra information about the procedure or patient.

Government and private insurers base payments on CPT codes . Each insurer has agreed to pay a fixed amount of money for each procedure or service identified by a CPT code. That payment may or may not be affected by a code modifier. Some modifiers, for example, indicate that the procedure took longer than usual to perform and thus triggers an additional payment.

Medical Billing

After obtaining diagnostic and procedural codes from medical coders, medical billers use billing software to prepare billings for submission to patients and insurers. Medical billers are responsible for making claims for payment and for following up with insurers and government agencies to assure that claims are paid.

When billings are rejected, medical billers track down and correct errors that caused the rejection. Medical billers are also the first line of communication between healthcare providers and patients or insurers concerning the accuracy of medical billings. When medical billers determine that the rejection of a claim was in error, the billers explain to insurers why the claim should be paid. When a billing is paid in part and a patient remains responsible for paying some or all of the balance, the medical biller answers the patient’s questions about the patient’s payment responsibility.

Medical billers often have primary responsibility for maintaining the cash flow of a medical practice. They may oversee invoice preparation and account payments. Medical billers might have authority to negotiate payment plans with patients. Medical billers may work with medical practice owners or their lawyers in deciding whether medical bills should be placed for collection.

Medical billers may work with coders when an insurer or government agency questions the accuracy of billing codes. While the coder has primary responsibility for selecting CPT codes, a medical biller may gather further information and ask the coder to revisit a coding decision that is questioned by an insurer or government agency.

Differences Between Medical Coders and Medical Billers

Both medical coders and medical billers are familiar with medical terminology. Medical coders may have more experience and training to help them understand and interpret the information contained in medical records.

Medical coders usually have more training in the nuances and complexities of medical coding than medical billers. Medical coders participate in continuing education that keeps them abreast of changes in the CPT codes that are instituted by the AMA.

Medical billers generally have a stronger background in bookkeeping methods that are common to medical billing. Medical billers need to master the particular software package used by their employer to generate medical bills.

Medical coders and billers are both expected to work efficiently and accurately. Both jobs require employees who pay careful attention to detail. However, medical billers have more contact with patients and insurers than medical coders. Communicating professionally with patients who are angry because they don’t understand a billing can be challenging. People who prefer working with data to working with people might find satisfaction in medical coding, while more extroverted individuals who want to work with data and people might be well suited to medical billing.

Smaller medical practices sometimes combine the roles of medical coder and medical biller. They do so to reduce employee overhead. Larger practices, hospitals, and companies that provide outsourced services to medical practices are more likely to hire employees who specialize either in coding or billing and to divide work duties accordingly.

Proven Ways to Avoid the Most Common Medical Billing Errors

Mon, 04 Apr 2022 13:12:00 GMT

Medical billing is a detail-oriented profession. People who are not meticulous about details are ill-equipped to work as medical billers. Accuracy is the most important part of medical bill preparation.

Getting billings right helps medical practices get paid on time. Errors cause billings to be rejected. Fixing mistakes takes time and delays payments. Too many errors can raise a suspicion of fraud or create a reputation for incompetence.

Here are the most common errors that medical billing experts see in medical billings. We also share our thoughts about how those errors can be prevented.

Record and Billing Mismatch

Billing one patient for services delivered to a different patient is a surprisingly common mistake . The error can be caused by the confusion of similar names or similar patient identification numbers.

Double checking is part of the meticulous nature that billing professionals should cultivate. Making sure the patient’s name and identification number in the medical records matches the name and number of the patient who is billed will save the biller from preparing a new bill when an insurer or patient complains about being billed for services that were never provided.

Data Entry Errors

Mistyping a patient’s identification number, date of birth, or CPT codes will frequently cause an insurer to reject a bill. While it may be possible to correct the error and to resubmit the bill, getting it right the first time depends on proofreading every detail of the billing before it is finalized.

Insurance Errors

Patients may have multiple insurers. Determining whether a billing should go to the patient’s primary health insurer, to a workers’ compensation insurer, or to an auto accident liability insurer is one of the biller’s first tasks. Submitting a bill to a former insurer after insurance coverage has changed will also cause a billing to be rejected. Spending a few minutes verifying the insurance company that should receive the billing will avoid payment delays.

Incorrect CPT Codes

Medical billers are trained to understand Current Procedural Terminology (CPT) codes. Selecting the correct CPT code is one of a biller’s most important — and most difficult — tasks.

Describing medical services and procedures in words creates room for ambiguity. The same service might be described in different ways, while different services might be described in similar ways. Five-digit CPT codes provide a standardized way of describing each procedure or service that a health care provider might render, making it possible for an insurer to understand what services or procedures are being billed without risking a misinterpretation of written descriptions.

The Centers for Medicare & Medicaid Services, which oversees the Medicare and Medicaid programs, incorporated CPT codes into its own system, the Healthcare Common Procedure Coding System (HCPCS). Billings to Medicare or Medicaid may be rejected when a biller errs in assigning a CPT code. When the bill is paid but the error is discovered during a billing audit, the provider may be required to refund fees that the government paid to the provider.

The American Medical Association (AMA) first developed CPT codes in 1966. The AMA has revised and expanded the coding system on several occasions. The codes are changed and updated regularly. New codes are added as the medical profession adopts new procedures and technologies. Keeping abreast of changes is the key to avoiding mistakes in assigning a CPT code.

Unbundling Charges

While each medical procedure has a unique CPT code, there are times when multiple procedures are performed at the same time. Rather than billing each procedure separately (a mistake known as “unbundling”), billers must determine whether a CPT code has been assigned to a group of services provided at the same time. If so, the biller should use that code rather than billing each procedure separately.

Unbundling may result in more revenue for the provider, but the reality is that multiple procedures performed during the same visit often take less time than multiple procedures performed during multiple visits. Using the correct CPT code to avoid unbundling assures that patients are not overbilled.

When a group of procedures takes longer than usual to perform, billers should use code modifiers to indicate the extended time rather than unbundling the charges. Learning how to use code modifiers, like learning how to use CPT codes, requires continuing education and training throughout a medical biller’s professional career. Staying current is essential to the avoidance of billing errors.

Improper Code Linkage

In addition to CPT codes, medical billers must use and understand diagnostic codes. A diagnostic code, based on the International Classification of Diseases (ICD), is assigned to each diagnosis of a disease or health condition that is documented in medical records.

Assigning the correct diagnostic code helps insurers understand why treatment was provided. An incorrect diagnostic code may create a disconnect between the billed procedure (as described by a CPT code) and the diagnosis. When a CPT code does not describe a procedure or service that would be a reasonable treatment for the diagnosed condition, the insurer will reject the bill. Payment will be delayed until the erroneous diagnostic code is corrected.

Errors in linking diagnostic codes and CPT codes are avoided by mastering both sets of codes. In addition, double checking every assigned code before the bill is submitted for payment will catch errors that could result in the bill being rejected.

Duplicate Billing

Billing twice for the same service or procedure is an obvious error. The error may result in overpayment of billings. When insurers catch the error in an audit, the medical practice will need to refund the extra payment. Medical practices may face liability if Medicare or an insurer suspects that the overbilling was deliberate.

Duplicate billing usually occurs because different people who handle billing for a provider input billing information for the same patient at different times. Assigning one biller to do all billing for the same patient is a way to eliminate errors. Alternatively, billers should review all previous billing entries to determine whether the same procedure or service has already been billed.

Using a Medical Billing Review Expert in a Wrongful Death Case

Mon, 28 Mar 2022 04:38:00 GMT

Wrongful death liability is primarily a creature of state law. While every state recognizes the right to sue for wrongful death, states take different approaches when they define the persons who can sue and the damages that are available.

In every state, however, a plaintiff who brings a wrongful death action can recover the victim’s medical expenses prior to death as an element of damages. Medical billing review experts help plaintiffs recover those billings. They also help insurance companies defend against an award of damages for unreasonable charges.

State Approaches to Wrongful Death Cases

A wrongful death is a death that is caused without legal justification. The death might be caused intentionally or negligently, although most intentional killings are handled in criminal prosecutions rather than civil lawsuits. Still, a murderer with substantial assets will sometimes be sued for wrongful death.

The plaintiff in a wrongful death lawsuit is determined by state law. The deceased victim’s estate may be entitled to pursue a wrongful death action. State law may give that right to certain close family members, including the victim’s spouse and minor children. Whether other relatives can join the lawsuit, and how the person who brings the suit must distribute the proceeds among eligible relatives, is also determined by state law.

Depending on state law and on the circumstances, damages may be recovered in either a wrongful death action or a survival action. A survival action is brought on behalf of the deceased for harms that the victim suffered before death. A wrongful death action is brought by or on behalf of the victim’s estate or heirs. Both kinds of lawsuits are often combined in a single complaint. The recovery of medical expenses may be possible in both a survival and a wrongful death action.

Recovery of Medical Bills in Wrongful Death Lawsuits

When the estate or the victim’s heirs paid the victim’s medical expenses related to the injury that caused the death, the estate or heirs may sue to recover those expenses. When a death was sudden and immediate — such as a death caused by a gunshot to the head — medical expenses may be minimal or nonexistent. In those cases, the estate or heirs may seek recovery of funeral expenses and other damages provided by state law, such as loss of financial support that the victim would have provided.

In many cases, however, medical expenses are substantial. A victim may linger in a coma for weeks before death is pronounced. Surgeons might perform multiple operations in an effort to extend or save the victim’s life before the victim dies. Palliative care for cancers caused by exposure to asbestos or other toxic substances in dangerous products can result in substantial medical bills.

Proof of Medical Expenses

Plaintiffs in a wrongful death or survival action can recover medical expenses related to the injuries that caused the victim’s death. Causation is typically proved by fact witnesses, treating physicians, and by other witnesses with knowledge of how injuries were sustained that resulted in medical treatment.

To recover those expenses, the plaintiff must proof that the treatment was necessary and that billings for the treatment are reasonable. Necessity is usually proved by a treating physician’s testimony that the billed services were needed to diagnose and treat the injuries.

Medical bills are reasonable when the charges are consistent with the usual and customary fees charged by other providers of the same services in the same community. The “usual” fee is the fee that the same provider charges other patients for the same services. The “customary” fee is the fee that comparable providers charge for the same services in the same geographic area.

Expert testimony is often essential to establish that a physician charged a usual and customary — and therefore reasonable — fee. Whether charges are reasonable cannot usually be established by medical testimony. A physician’s opinion that his or her chares are reasonable does not meet the evidentiary standard for proof of reasonableness.

Doctors usually have no personal knowledge of the prices charged by competitors. They often admit on cross-examination that they have not surveyed other doctors in their area to determine the amount they charge for the kind of services that are reflected in a medical billing.

Using an Expert to Prove that Medical Expenses Are Reasonable

Since jurors do not understand whether charges in a community are usual and customary, expert evidence is typically needed to prove the reasonableness of fees. The federal Daubert standard and its state counterparts require expert to testimony to be based on sufficient facts and a reliable methodology that experts apply to the facts in a reliable way. Physicians might have anecdotal conversations with other doctors about fees, but they can rarely claim to have used a reliable methodology to determine whether their charges are reasonable.

Familiarity with billing and diagnostic codes gives medical billing experts specialized knowledge that ordinary jurors do not possess. Courts agree that medical billing experts do not need medical training to qualify as expert witnesses.

Medical billing experts satisfy the Daubert standard by gathering sufficient facts and data. They review medical records to determine whether the billings are accurate and whether they reflect the correct billing codes. They base opinions on databases that record the actual costs of specific medical services within a community. Courts consider those facts to be sufficient to support an expert’s analysis of a medical billing.

Medical billing experts also derive their opinions from reliable methodologies. They use databases to determine the actual prices charged by other physicians in the same area for the same services. That analysis allows the expert to determine whether the medical billing falls within a reasonable range of charges for the same services or is substantially higher.

By adhering to methodologies that satisfy Daubert , medical billing review experts offer admissible expert testimony in wrongful death cases. Whether called by a plaintiff to establish that bills are reasonable or by a defendant to challenge reasonableness, a medical billing review expert is an essential witness in wrongful death litigation.

Medical Billing Review Expert in a Products Liability Case

Mon, 21 Mar 2022 11:01:00 GMT

Medical expenses are a common component of damages in a products liability case. Severe injuries caused by dangerous products often require prolonged care, including multiple surgeries and burn treatment.

Medical expenses are recoverable as damages, but they are not awarded automatically. Injury victims must typically prove that necessary medical expenses are reasonable. A medical billing review expert is in the best position to offer evidence that will satisfy that standard.

Defense lawyers often challenge the award of medical expenses on the ground that billings are inflated or unreasonable. Expert testimony based on a medical billing review provides defense counsel with evidence to support that challenge.

Products Liability Damages

Most products liability lawsuits involve personal injuries. Whether the case is based on a theory of negligence or strict liability, compensatory damages are available to plaintiffs who were injured by a defective or poorly designed product.

Damages typically include past and future medical expenses, lost wages and loss of earning capacity, and the cost of coping with a disability. In addition to those economic losses, state law generally allows damages to be awarded for pain and suffering, including emotional distress that arises from a physical injury.

When lawyers settle cases, they are typically guided by medical expenses and lost wages. Lawyers might use a multiplier of economic losses as a starting point to assess the settlement value of pain and suffering.

Studies show that juries often do the same thing. While jury verdicts vary widely, scholars who have averaged personal injury verdicts over time have discovered a pattern. Juries are not instructed to base awards for pain and suffering on multiple medical expenses and lost wages, but verdicts for pain and suffering tend to increase as awards for economic damages increase.

Consequently, medical expenses have an impact on product liability verdicts in two ways. First, when injuries are serious and require extensive or expensive medical care, they can be a large component of the total verdict. Second, larger awards for medical expenses tend to drive larger awards for pain and suffering.

Medical Billing Reviews for Plaintiffs

Plaintiffs have an incentive to recover the full amount of their medical billings even if they did not pay those bills from their own pockets. Health insurance often pays a portion of medical billings. In many cases, doctors accept the health insurance payment as full payment, even if the health insurance payment is significantly less than the amount billed. Plaintiffs typically rely on the collateral source rule to seek a verdict for the full amount billed even if they paid only a small part of the bill as an insurance deductible.

In most states, plaintiffs can only be compensated for reasonable medical expenses. Some states presume that any portion of the bill that was paid is reasonable. Other states do not follow that rule. In any event, significant portions of billed medical expenses are often unpaid. Proving the reasonableness of the full bill, whether or not it has been paid in full, is a key to obtaining a full award of medical expenses.

Whether a medical bill is reasonable depends on whether if reflects the usual and customary charges for services within the community. Reasonableness is a question of fact that must often be established through the testimony of an expert witness. A doctor’s personal opinion that his or her charges are reasonable rarely has a sound foundation. Unless doctors are aware of what other doctors in the community recharging, they cannot know whether their own charges are consistent with customary charges within that community.

Particularly when states follow some version of the Daubert rule, judges increasingly require reasonableness to be established by expert evidence that satisfies the Daubert standard. Medical billing experts are routinely allowed to testify that medical bills are or are not reasonable. They satisfy the Daubert standard by basing their opinions on adequate facts and a reliable methodology.

Medial billing experts compare the charges in a medical bill to the charges that are customary within the relevant geographic area. They determine customary charges by consulting databases that gather actual billing data for the same charges within the same zip code (or a set of related zip codes). Databases provide billing experts with reliable data upon which to base opinions.

Medical billing experts understand that some physicians charge more than others, usually because of their superior credentials or experience. Billing experts also know that some procedures are more complex than others. They take note of billing codes to determine the complexity of procedures.

After considering all facts, medical billing experts make a reliable assessment of whether billings fall within a range of reasonable charges. That analysis leads to testimony that plaintiffs can use to prove the reasonable charges that juries should award. Juries, in turn, typically consider reasonable medical expense when they return a verdict for pain and suffering.

Medical Billing Reviews for Defendants

Defendants use medical billing experts to challenge the reasonableness of medical expenses. Medical billing experts help defendants in several ways.

First, medical billing experts make a line-by-line comparison of medical bills to medical records. If there is no evidence that billed treatment was ever provided, they conclude that the billing for that treatment was unreasonable.

Second, medical billing experts determine whether the Current Procedural Terminology (CPT) codes in the billing accurately describe the services and procedures that were rendered. Billing departments often use an incorrect CPT code that results in overbilling.

Third, medical billing experts look for common errors in the application of CPT codes. For example, billers may “unbundle” charges for multiple services or procedures that were provided at the same time by assigning a separate CPT code to each one. That practice results in overbilling when a different CPT code is intended to cover multiple procedures that are performed at the same time.

Finally, medical billing experts can help defendants understand whether billings are unreasonable because they are substantially higher than the usual and customary charges within the community where the services were provided. Expert testimony can help the defendant establish that charges are unreasonable and therefore not awardable as damages.

Medical Billing Review Expert in Medical Malpractice Cases

Mon, 14 Mar 2022 06:54:00 GMT

Like any other personal injury case, medical malpractice victims are entitled to recover reasonable medical expenses they incur as a result of their physician’s negligence. Medical billing review experts help lawyers prove or disprove the reasonableness of those expenses.

Unlike most other personal injury cases, a medical billing review expert might be able to help lawyers prove that malpractice occurred. A careful comparison of medical records to billing records will sometimes provide evidence that the medical records were altered, perhaps to cover up negligence.

Proving the Reasonableness of Medical Expenses

Medical malpractice may result in prolonged care to alleviate the harm caused by the negligent doctor. Surgical malpractice may result in surgical revisions. Prescribing a medication overdose or a medication to which a patient has an allergy may require further hospitalization to treat the resulting harm. The expense of diagnosing and treating harms caused by malpractice is an element of the malpractice victim’s damages.

State law typically requires an injury victim who seeks reimbursement of medical expense to prove that the expenses were reasonable and necessary. A treating physician can explain why the billed treatment was necessary. Treating physicians, on the other hand, may not be well positioned to testify about the reasonableness of medical expenses.

Medical expenses are reasonable when they are the usual and customary charge for a medical service or procedure. The “usual” fee is the fee that the same provider charges other patients for the same services. The “customary” fee is the fee that other providers charge for the same services in the same geographic area. Treating physicians might know what they usually charge for a service, but they rarely have more than anecdotal knowledge of the fees that other physicians charge for the same services.

Since ordinary jurors do not know whether a particular charge for a medical service is reasonable, plaintiffs must typically present expert evidence to establish reasonableness. Judges who take a strict view of Daubert and similar state standards for the admission of expert testimony will not accept a doctor’s unsupported opinion that “My charges are reasonable.”

The Daubert standard requires an expert opinion to be based on sufficient facts, a reliable methodology, and the reliable application of the methodology to the facts. A physician who has not surveyed the fees charged by other doctors lacks sufficient facts to support an opinion.

Nor do physicians base their opinions on a reliable methodology when they express a personal opinion that their fees are reasonable. Courts increasingly reject that testimony because it is unsupported by a reliable method for reaching conclusions.

Medical billing experts overcome Daubert objections by basing their conclusion on sufficient facts and a reliable methodology. To form an opinion about the reasonableness of a billing, they compare the billing codes to the medical records to determine the billing’s accuracy. They then consult established databases to determine the fees charged by other physicians in the same community for the same services as those that were billed.

Medical billing review experts, unlike most physicians, base their opinions on standardize methods that are accepted within their field of expertise and that produce reliable results. For that reason, judges routinely admit the opinion testimony of medical billing review experts.

Proving Malpractice

Lawyers primarily rely on medical experts to establish a standard of care, a breach of that standard, and the causal link between the breach and the injury. A thorough expert review of medical billings will sometimes add additional evidence that cements the plaintiff’s case.

Studies of doctors who commit malpractice have concluded that doctors frequently attempt to conceal their mistakes or shift the blame to the patient or other doctors rather than admitting their errors. Doctors who do not want to impair their professional reputations may alter medical records to hide their mistakes. Hospital administrators sometimes encourage or abet the physician’s deception to protect the hospital from liability.

Surveys have found that 7% of doctors believe it is acceptable to hide errors from patients, while another 14% feel it is acceptable to hide the truth under some circumstances. In reality, the surveys probably undercount the extent of physician dishonesty. It is easy for a physician to tell someone taking a survey that he or she would never conceal a mistake. When push comes to shove, however, a certain percentage of physicians who thought of themselves as honest will take the path of self-interest.

Altering medical records is the most common way to conceal medical negligence. Doctors might change medication records to make it appear that they prescribed a different medication than the one that was administered to a hospitalized patient. They might alter patient histories to make it appear that a patient never told them about an allergy. They might indicate that they advised a patient to obtain a test that the doctor never discussed with the patient.

In some cases, altered medical records result in “doctor said – patient said” credibility contests. In a percentage of those cases, a medical billing expert can detect evidence that the patient records were changed.

Billing records contain diagnostic and procedural codes. Billings are often issued before a physician changes medical records to conceal a mistake. It is less easy to change diagnostic and procedural codes since billings have already been sent to the patient and the patient’s insurer.

If medical records show that a doctor made a diagnosis when a lawsuit contends the doctor erroneously failed to make the diagnosis, the absence of that diagnostic code in the billing records may be evidence that the medical records were altered. If medical records show that services were provided or procedures were performed that are not reflected in billing codes, the absence of those codes may also be evidence that the records were changed.

Evidence that medical records were altered can be compelling evidence that challenges a physician’s credibility. Medical billing review experts can thus help prove liability in some malpractice cases.

Using a Medical Billing Review Expert in Motor Vehicle Accident Cases

Mon, 07 Mar 2022 06:55:00 GMT

Lawyers for plaintiffs and defendants face challenges when plaintiffs seek reimbursement of medical bills as damages in a motor vehicle accident case. Plaintiffs must prove that the bill is reasonable. Defendants might face a presumption that any portion of the bill that was paid by insurance or the plaintiff is reasonable. Even when that presumption does not arise, defendants have an incentive to reduce the verdict by presenting evidence that the bill is unreasonable.

A medical billing review by a qualified billing expert in vehicular accident cases serves multiple purposes. First, the review alerts the attorney to potential issues related to the recovery or defense of medical expenses as an element of damages. Second, the review highlights expert opinions that lawyers can offer in court to prove or defend against a claim for medical expense reimbursement. Third, medical billing reviews promote settlement by giving lawyers a better understanding of the amount of medical expenses that a jury is likely to award.

Proof of Reasonable Medical Bills

Plaintiffs who are injured in motor vehicle accidents because of a driver’s negligence are entitled to recover reasonable and necessary medical expenses that they incurred because of the defendant’s negligence. Causation is typically proved with a combination of fact witnesses, treating physicians, and (on occasion) expert witnesses who testify that that the accident caused the injuries for which the plaintiff was treated. Necessity is usually proved by a treating physician’s testimony that the billed services were required to diagnose and treat those injuries.

The reasonableness of those charges, on the other hand, cannot necessarily be established by medical testimony. When the bills are small, parties might stipulate that they are reasonable. A defendant might also respond to a request for admissions by admitting that the charges are reasonable. When bills are more substantial, however, whether they are reasonable is often a disputed issue.

In some courts, a judge who has a lax attitude about the proof of reasonableness might allow a doctor to testify that his or her charges were reasonable. However, judges increasingly agree that “I think my fees are reasonable” is not an adequate foundation for an opinion that fees are reasonable.

Using an Expert to Prove that Medical Expenses Are Reasonable

It is risky to use a treating physician to prove that the physician’s fees are reasonable. Physicians usually have no knowledge of charges other than their own, including hospital bills. Doctors often admit on cross-examination that they have not surveyed other doctors in their area to determine the amount they charge for the same services that are reflected in a medical billing. They might have anecdotal conversations with other doctors, but they have not used a reliable methodology to determine whether their charges are reasonable.

In federal court, and increasingly in state courts that have adopted some version of the Daubert rules, judges are declining to admit a doctor’s personal opinion that his or her charges are reasonable. The Daubert standard requires qualified experts to base opinions on sufficient facts and on a reliable methodology that they apply to the facts in a reliable way.

Since jurors do not know whether billed charges are consistent with usual and customary charges within a community, reasonableness must be proved by an expert opinion. Expert opinions must be based on reliable methodologies and supported by adequate facts. Opinions based on anecdotal evidence do not meet that standard.

Courts recognize that medical billing experts are qualified when they have training and experience that most people lack. Familiarity with billing and diagnostic codes gives medical billing experts specialized knowledge that ordinary jurors do not possess. Courts agree that medical billing experts do not need medical training to qualify as expert witnesses.

Medical billing experts gather sufficient facts and data by reviewing medical records, billings, and databases that record the actual costs of specific medical services within a community. Courts consider those facts to be sufficient to support an expert’s analysis of a medical billing.

As all medical billing experts use the same fundamental principles to determine whether charges are reasonable, their methodology is widely accepted as reliable within their field of expertise. Eliciting testimony about the expert’s methodology and training provides the court with a basis for determining that the expert’s opinion satisfies the Daubert standard.

Using an Expert to Defend Against Claims that Medical Expenses Are Reasonable

Even when a jurisdiction presumes the reasonableness of paid bills, defendants are allowed to challenge that presumption. Defendants are also free to challenge the reasonableness of bills that an insurer did not pay, even if the collateral source rule allows plaintiffs to recover medical expenses that a provider will never attempt to collect.

In addition to reviewing medical bills for reasonableness, billing experts determine whether a provider has made billing errors that result in an overcharge. Experts perform a line-by-line analysis of medical bills, looking for double charges or mistakes (such as data entry errors) that result in erroneous charges. They compare medical records to medical billings to determine whether the billing reflects the services that were provided.

Medical billing experts rely on their understanding of billing codes to assure that the billing does not reflect a more expensive service than the service that the patient received. They examine billings for “ unbundling ” errors that occur when doctors use billing codes for separate services that were provided at the same time. Since lay members of a jury are not trained to interpret billing codes, expert knowledge provides the foundation of the expert’s opinion.

How Do Plaintiffs Prove that Medical Bills Were Reasonable and Necessary?

Mon, 28 Feb 2022 07:21:00 GMT

Victims of personal injuries can seek reimbursement of medical expenses from parties who are liable for their injuries. In typical cases, victims must prove liability with evidence that the defendant was negligent and that the negligence caused an injury. In most jurisdictions, injury victims who seek reimbursement for medical expenses incurred to treat the injury must also prove that the expenses were “reasonable and necessary.”

Under some circumstances, injury victims might make a claim against their own uninsured motorist coverage or Personal Injury Protection (“no fault”) insurance for payment of medical expenses that were caused by another driver. Proof of those claims may be affected by the language of the insurance policy or (in the case of “no fault” coverage) by a state statute. Contracts and statutes may limit liability for medical expenses.

In most negligence cases, however, reasonable and necessary medical expenses are recoverable as damages. The words “reasonable” and “necessary” refer to two different standards. While both standards must be satisfied, they are typically proved with different kinds of evidence.

Proof of Necessity

The liable party must reimburse the injury victim for services reflected in a medical billing if the services were medically necessary. Services are necessary when they are required to diagnose, treat, cure, or relieve an injury or a symptom of an injury for which the party is liable.

The necessity of billed services is usually established by the testimony of the treating healthcare providers. For example, when treatment is provided by a surgeon and by a chiropractor, the surgeon and chiropractor will each testify that they provided services to treat, cure, or alleviate symptoms of a health condition that was caused by the responsible party. While other witnesses may also testify about causation, treating providers are usually in the best position to explain why it was necessary to provide the services that are reflected in medical billings.

In some cases, courts allow a physician to testify that services provided by others were necessary. For example, a treating physician might testify that all the services reflected on a hospital bill, including nursing services and the administration of tests or medications, were necessary even if the physician did not personally provide all those services.

Defendants and their insurers sometimes contest medical necessity. They might do so by presenting evidence that the injury was not caused by the accident that is the subject of the lawsuit. Defendants might also call their own medical experts to challenge the necessity of treatment for a condition caused by the accident. A defense expert might testify that the victim’s physicians “overtreated” the condition by providing unnecessary services or that more conservative and less expensive treatment was the only necessary treatment.

Proof of Reasonableness

A charge for a medical service is reasonable when it reflects the usual and customary charge for that service within the same geographical area. The usual charge is the charge that the same physician charges other patients for the same service. The customary charge is the charge that other physicians of comparable experience and skill within the same community charge for the same service.

A customary charge is not necessarily the average charge for the same service within the community. Some providers charge higher fees because they have more experience or skill than average providers. When medical billing experts determine whether a charge is reasonable, they understand that a range of charges, not just the average charge, might be reasonable. On the other hand, when a physician with average training and experience is charging substantially more than the average fee charged by physicians in the same community for the same service, that physician’s charge might be unreasonable.

Whether the charges billed for necessary services are reasonable cannot usually be established by the testimony of a treating physicians. Although some courts admit a treating physician’s testimony to prove that the physician’s bills are reasonable, cross-examination often reveals that the physician has no knowledge of customary charges within the community for the same services.

In some states, a charge that has been paid is presumed to be reasonable. That rule is based on the belief that neither the victim nor the victim’s insurer would pay an unreasonable bill. Regardless of any presumption, the defendant is entitled to challenge the reasonableness of a medical billing.

In most states, the collateral source rule allows the victim to collect the unpaid portion of the bill even if the provider agreed to accept a lesser amount from an insurer as full payment of the bill. To the extent that total bill exceeds the portion that is paid — as is often the case when the bill was submitted to a health insurer for payment — the unpaid portion is not presumed to be reasonable. The injury victim will therefore need to prove the reasonableness of the unpaid portion.

Expert Opinions Regarding Reasonableness of Medical Bills

Medical billing experts help plaintiffs prove that their bills were reasonable. They base their opinions on methodologies that state and federal courts have repeatedly accepted. They apply those methodologies to the facts of the case and write comprehensive reports that support their opinions.

Medical billing experts compare the CPT billing codes on medical bills to the medical records to assure that the billed services were provided and that the code correctly reflects those services. That analysis helps plaintiffs’ attorneys avoid placing claims before the jury that the defense can easily attack.

Medical billing experts then compare the charges to billing data collected by reputable database companies to determine the fees other providers within the same community have charged for the same services. That comparison provides an objective basis for an opinion that the charges are customary. If the charges are higher than average, the expert will determine whether the charges fall within a reasonable range, given the physician’s experience.

Medical billing experts offer an objective, data-driven analysis of reasonableness that treating physicians are not positioned to provide. Because billing experts rely on solid data rather than anecdotal evidence, billing experts can withstand cross-examinations that undermines physicians who testify to their personal beliefs that they charged reasonable fees.

Medical Billing Testimony Allowed in Accident Case

Mon, 21 Feb 2022 05:23:00 GMT

The substantive law of personal injury damages is determined by state court precedent. Nearly all states require accident victims who seek recovery of medical bills based on negligence claims to prove that the bills are reasonable. While precedents vary (some states, for example, presume reasonableness to the extent that bills have been paid), proof of reasonableness is generally a condition of recovering past or future medical expenses.

Proof of reasonableness is usually regarded as a procedural issue rather than a question of substantive law. While federal courts must follow state court precedent as to the need to prove reasonableness, the means of proving reasonableness in federal court is usually a matter of federal law. State and federal courts are nevertheless in general agreement that the testimony of medical billing experts may be used to prove reasonableness.

State and federal courts around the country have recognized the importance of expert testimony to prove the reasonableness of medical bills. Florida follows that general trend. The seminal state court case regarding medical billing experts was decided in 2012.

Facts of the Bowling Case

Twyman Bowling was injured in an automobile accident. Unfortunately for Mr. Bowling, the driver of the vehicle who caused the accident was uninsured. Fortunately, Mr. Bowling had uninsured motorist insurance. When his insurer, State Farm, denied his claim, Mr. Bowling sued State Farm to recover damages for his injuries.

Mr. Bowling presented evidence that he received medical bills in the approximate amount of $278,000. A jury awarded $944,154.50 in damages. The trial court reduced that award to the policy limits of $100,000.

A key issue before the jury was whether Mr. Bowling was fabricating or exaggerating his injuries and whether the medical expenses were reasonable. The trial court excluded the testimony of a medical billing expert who would have opined that $111,000 of the medical bills were unsupported by any medical billing codes. Billing codes are used to establish the precise nature of medical services and procedures that were provided. Medicare and private insurance companies typically deny reimbursement for services that are not supported by billing codes.

State Farm’s expert testified in a deposition that she compared the bills to the medical treatment records and found “extreme abuse in regards to the coding, billing, and medical record documentation” of four of Mr. Bowling’s main medical care providers. She testified that as for those four providers, “there is absolutely nothing within that documentation that is supportive or representative of any of the billed procedures that I have reviewed.”

State Farm contended that its billing expert would have provided admissible evidence and that the trial court erred by excluding the expert’s testimony. State Farm appealed the judgment to the Florida District Court of Appeals. The appellate court agreed with State Farm.

Billing Expert’s Proof of Reasonableness

In Florida, as in most states, a plaintiff who wants to recover medical expenses must establish that the billed services were necessary and that the charges were reasonable. Necessity is typically established by the testimony of treating physician’s and is typically challenged with the testimony of medical experts retained by the defense.

Reasonableness, on the other hand, need not be proved with medical testimony. In fact, while doctors may testify that their bills are reasonable, cross-examination often reveals that they have no personal knowledge of the fees charged by other physicians in their community for the same services.

When they profess to have knowledge of a community’s medical billings, doctors often admit that they are basing their opinions on anecdotal evidence rather than a survey of customary charges. Medical billing experts overcome those deficiencies by basing opinions on databases that record charges billed for the same services within the relevant geographic area.

The trial court decided that the medical billing expert was not qualified testify as an expert witness. The appellate court disagreed. The witness had taken specialized courses in medical coding and had passed a national examination in coding. She had sufficiently specialized knowledge and training to express an expert opinion on whether the medical bills were properly coded and whether they corresponded to the medical records documenting the purported treatment. She also had experience testifying as an expert for a variety of lawyers, for the insurance industry, and for various businesses.

The medical billing expert was not qualified to testify whether the medical treatment that was rendered was reasonable, but she was not asked to do that. She was well qualified to opine that the billings reflected treatment that was not documented in the medical records. The expert’s testimony was therefore relevant to State Farm’s defense that Mr. Bowling’s medical providers fabricated or exaggerated the medical care necessary for his alleged injuries.

The appellate court concluded that State Farm had a due process right to present a qualified expert witness who had specialized knowledge that was relevant to its defense. Because the trial court violated State Farm’s right to a fair trial, the court reversed the judgment and remanded the case for a new trial.

Bowling Standard Followed in Florida Cases

State and federal courts in Florida have concluded that the Bowling decision states the law correctly. In 2020, another Florida District Court of Appeal cited Bowling for the proposition that a trial court should exclude a witness only “under the most compelling of circumstances,” especially where excluding the witness will leave a party unable to present evidence supporting her theory of the case.

A federal court recently applied the Bowling standard in a related context. That court allowed a witness to testify as an expert in medical coding when the testimony was relevant to the plaintiff’s false claims case. The plaintiff asserted that the defendant was overbilling the government for medical services.

Applying the federal Daubert standard, the court determined that the medical billing expert formed opinions by applying a reliable methodology to sufficient facts. The court agreed with the plaintiff and with Bowling that a qualified medical billing expert is able to give relevant testimony when the correctness of medical billings is an issue in the case. Thus, in both federal and state courts in Florida, medical billing experts can give admissible testimony when the correctness or reasonableness of medical billings is an issue in the case.

Medical Billing Expert Witness Testimony Allowed

Mon, 14 Feb 2022 11:45:00 GMT

Medical billing experts are important witnesses for both plaintiffs and defendants. Courts routinely recognize that medical billing experts can give relevant testimony that satisfies the Daubert standard of admissibility. A recent case before a federal judge in Texas illustrates why the testimony of medical billing experts is admissible.

Facts of the Case

In Cornejo v. EMJB, Inc. , Richard Cornejo and his wife sued the driver of a tractor-trailer and the company that owed the vehicle. The Cornejos alleged that the truck driver was in the middle lane of a freeway when he made an unsafe lane change, striking the car that Richard Cornejo was driving. Richard’s wife was a passenger in that car. Both plaintiffs alleged that they sustained severe injuries because of the truck driver’s negligence.

The Cornejos contended that the truck driver committed gross negligence by operating a cellphone at the time of the collision. Phone records established that a 39-minute call coincided with the time of the accident. The court decided that the evidence of gross negligence was sufficient to present a jury issue. The more significant question before the court was whether to admit the testimony of the defendants’ medical billing expert.

Medical Billings and Proposed Expert Testimony

Texas law includes a unique procedure that governs the proof of reasonableness of medical bills. That procedure requires a plaintiff to submit proof of medical billings by affidavit. If the defense challenges the reasonableness of the billings, it must do so by counter-affidavit. That procedure, however, does not apply when the lawsuit is brought in federal court. Presumably for that reason, the Cornejos did not submit an affidavit regarding their medical expenses.

During discovery, the Cornejos disclosed the past and future medical expenses that they incurred as a result of the collision. They obtained chiropractic and pain management treatment from TriCity Pain Associates. They proposed to enter into evidence a billing for those services rendered in the amount of $68,000. The defendants’ medical billing expert submitted a report explaining that the reasonable value of the services rendered should not exceed $3,000.

The Cornejos also intended to introduce evidence of their need for future spinal surgeries. They intended to offer evidence that they would be billed about $300,000 for all costs associated with the surgeries. The defendants’ medical billing expert testified that the reasonable cost of the surgeries is less than $22,000.

The Cornejos did not submit any of their billings to an insurance company for payment. Given their self-pay status, their liability for payment of the bills is evidence that the bills are reasonable under Texas law. However, defendants are entitled to challenge the reasonableness of the bills.

The Cornejos filed a Daubert motion to exclude the testimony of the defendants’ medical billing expert. Federal Rule of Evidence 702 requires judges to determine whether proposed expert testimony is both relevant and reliable. The Daubert standard of reliability requires an expert to be qualified to give an opinion in a specialized area of knowledge and to base that opinion on a reliable methodology that the expert reliably applies to sufficient facts.

Qualifications of Medical Billing Expert

The court had little difficulty concluding that the expert was qualified to testify. He had a master’s degrees in healthcare administration (MHA), health services (MHS), and business administration (MBA). He conducts medical billing reviews as part of his work with the Texas Medical Foundation.

The Cornejos objected that the witness has no expertise in pain management or orthopedic medicine. The Cornejos confused the question whether treatment is necessary with whether fees charged for that treatment are reasonable. The necessity of treatment is usually established through the testimony of the plaintiff’s treating physician. The defense is free to call medical witnesses to challenge that testimony, but their medical billing expert did not speak to the issue of necessity. He was retained solely to testify about the reasonableness of the fees charged.

A medical billing expert need not be a physician who practices in the same field of medicine as the providers of the billed services. In fact, the court recognized that a medical billing expert need not be a physician at all. The court noted that “nonphysicians can provide expert testimony on medical costs, so long as they have access to and experience with billing databases that provide the basis for their opinions.” The court noted that medical billing experts are often in a better position to testify about the reasonableness of costs than physicians, who typically focus on their own practice and are unfamiliar with the fees charged by other physicians for similar services.

Reliability of Testimony

The court determined that the defense expert’s methodology was reliable. The billing expert consulted reimbursement rates paid by several insurance companies, as well as reimbursement rates paid by Medicare, for the services that were or will be provided to the Cornejos. The expert also consulted a billing database to determine the average fees paid to providers for services that were identified by the same CPT code as services for which the Cornejos seek damages.

The most relevant objection advanced by the Cornejos was that the expert drew data from his own database of fees charged in the San Antonio area, while the services were or will be provided in the Dallas-Fort Worth area. Since both geographic areas are within Texas, the court held that the discrepancy went to the credibility of the testimony rather than its admissibility. Most medical billing experts, however, avoid that problem by relying on commercial databases that allow them to pinpoint the cost of services with the zip code where the services were delivered.

The court concluded that Daubert factors applicable to scientific research — whether the results of a methodology have been replicated, whether the results have been peer reviewed, whether there is a known error rate — do not apply to the “straightforward” methodology used by medical billing experts. The court concluded that the comparison of fees charged to a database of fees is a reliable way to determine reasonableness of medical charges. Whether the database is adequate might implicate the sufficiency of the data upon which the expert relies, but the court concluded that arguments about the adequacy of the database could be addressed on cross-examination. The court therefore admitted the testimony of the medical billing expert.

Future Medical Cost Projection Versus Life Care Planning

Mon, 07 Feb 2022 11:14:00 GMT

Life care plans are commonly prepared for litigation to prove future damages in personal injury cases that involve a catastrophic injury. Medical cost projections are a routine part of life care planning. Medical cost projections can also be useful for trust administrators who need to project future care expenses for a trust beneficiary, for insurance companies that need to set reserves for claims involving the payment of anticipated expenses, to determine Medicare set-asides in workers’ compensation cases, to guide estate plans, and for other purposes that require the projection of expenses for future healthcare.

Medical cost projections are often prepared as a separate document when a full life care is not required. In situations that do not involve litigation, a medical cost projection may be all that a client needs. A standalone medical cost projection is a less comprehensive document than a life care plan and is usually insufficient for lawyers who are seeking future damages for a catastrophic injury victim. However, life care planners may rely on cost projections prepared by a medical billing expert when they prepare a life care plan.

Life Care Plans Versus Medical Cost Projections

Life care plans identify the current and future needs of individuals who have been impaired by a catastrophic injury or a chronic health condition. Those needs generally include medical care, including monitoring a health condition, performing diagnostic testing, prescribing medications, and performing future surgeries. Other medical services that may be necessary in the future include physical therapy and (particularly when an accident victim has a traumatic brain injury) psychological or psychiatric treatment.

Some future needs are not necessarily “medical” in nature. A life care plan might be combined with or accompanied by a vocational assessment that considers future employability and the impact of injuries on future earning capacity. When the client is capable of working, a life care plan will consider the cost of vocational rehabilitation to maximize the client’s independence. Helpers who are hired to clean a home, maintain a lawn, prepare meals, and perform other tasks that an injury victim can no longer accomplish generally provide no medical services.

Other needs might be filled by people who have some medical training, even if they are not providing medical treatment. A caregiver who assists with the tasks of daily living (such as eating, bathing, and getting dressed) might be trained in certain nursing skills, including managing and administering medication, treating bedsores, and operating home-based medical equipment.

In some cases, a disabled individual might need care that is best provided in an institution. Some individuals might need the full-time nursing care that is offered by a nursing home. Others might be better suited for an assisted living facility, where care focuses on assistance with the activities of daily living and occasional health monitoring or treatment by skilled nurses. A specialized facility might be appropriate for individuals who suffer from traumatic brain injuries or dementia.

Catastrophic injury victims with impaired mobility who can live independently (with or without caretaker assistance) will likely need to use specialized transportation services or acquire a wheelchair-accessible van. They may need to add ramps and chair lifts, widen entrances, and lower counters to make an existing home usable. The costs of adapting or acquiring property so that injury victims can live independently are documented in a lifecare plan.

Life care plans take account of all future expenses that are necessary to cope with a disability, not just medical expenses. However, future medical expenses are a key component of life care plans.

Future Medical Cost Projections

Projecting future medical costs begins with a comprehensive review of medical records. The review should include not just a physician’s examination or discharge notes, but also nurse’s notes, laboratory and diagnostic test results, emergency records, ambulance reports, and physician’s orders.

The expert may or may not need to speak to the disabled individual. That interview is essential when preparing a life care plan but may not be necessary when preparing a future medical cost projection. It may, however, be necessary to interview treatment providers to develop a full understanding of a client’s future medical needs, including members of the therapeutic team who participate in developing the individual’s treatment plan.

After identifying all future treatment needs that are either certain or likely, a medical billing expert researches the cost of meeting those needs. Since costs vary from place to place, experts must consult databases that record the actual costs physicians have charged for the identified services within the client’s zip code. Experts may need to supplement that data with their own research when the database is inadequate.

Medical billing experts use other standardized references, in addition to catalogs and online searches of medical supply companies, to obtain the costs of wheelchairs and other needed medical equipment. Research studies help experts understand the durability of medical products and the frequency with which they will need to be replaced.

Common Categories of Future Medical Expenses

Every case is different. Future medical costs can only be determined by assessing the particular needs of an individual, as those needs are evidenced by medical records, physicians, care providers, and references that define the standard of care for particular disabilities. Depending on the disabled individual’s needs, future medical costs might include:

Cost of monitoring and treatment , including:

Cost of Future Surgeries , including:

Cost projections for future surgeries include:

Cost of prosthetic and medical devices , including:

Cost of future medications , including:

Cost of assistants , including

Cost of institutionalized care , including

This list is illustrative, not comprehensive. Medical billing experts consider costs for all identified services that a disabled individual will likely need in the future when they prepare a medical cost projection.

What Changes in Medical Billing Services Should You Expect in 2022?

Mon, 31 Jan 2022 11:18:00 GMT

Every year brings new changes in the way medical billing services must operate. In 2022, those changes will include new CPT codes, a new ICD system, and new ways of doing business.

Hospitals, clinics, and medical practices are increasingly outsourcing their production of medical billings. The market for medical billing services increased by 9.4% in 2019, by 10% in 2020, and by 10.3% in 2021. Industry analysts project annual growth in medical billing outsourcing of more than 12% by 2028.

To meet the increasing demand for medical billing services, medical billing companies are increasing their hires of trained and qualified medical billers and coders . The Bureau of Labor Statistics projects that the medical billing and coding job market will grow by 22% through 2026.

Coders always have a lot to learn to keep up with the changing demands of the job. Here are some of the changes that the medical billing industry will see in 2022.

New CPT Codes

Current procedural terminology (CPT) codes are always a work in progress. As physicians adopt new procedures, the American Medical Association creates new CPT codes to describe them. The Centers for Medicare and Medicaid Services (CMS) also dictates changes to CPT codes that must be used when billing Medicare and Medicaid.

About 250 new CPT codes have been adopted or will likely be adopted for use in 2022. Several new codes relate to COVID-19 vaccines, including codes for booster shots and vaccine administration. Other new codes relate to therapeutic remote monitoring and principal care management.

New ICD System

In addition to mastering new CPT codes, billers and coders will eventually transition to a new system of coding symptoms, diseases, and other medical conditions. Insurance companies have increasingly required billings to reflect the International Statistical Classification of Diseases and Related Health Problems (ICD) developed by the World Health Organization (WHO).

The tenth revision of the ICD (ICD-10) was implemented in 1994. Its use in the United States became widespread in 2015, when CMS mandated ICD codes for all billings that are covered by the Health Insurance Portability and Accountability Act (HIPAA).

The WHO’s eleventh revision (ICD-11) took effect in January 2022. At this point, the CMS has not mandated the replacement of ICD-10 with ICD-11 in the United States. Given that ICD-10 is clinically outdated, a transition to the international standard is inevitable. The only question is when ICD-11 will be implemented in the US. Coders will at least want to be trained with an overview of ICD-11 so that they can begin to prepare for a transition to ICD-11 when it is finally implemented.

No Surprises Act

The No Surprises Act (NSA) requires most emergency services to be covered by insurance, even if they are provided by an out-of-network provider. When an insured patient receives any services at an in-network facility, the NSA bans the practice of billing the patient for services rendered by out-of-network providers unless the patient has been advised of those services in advance and consents to pay for them.

The NSA presents challenges to the collection of medical bills by out-of-network providers. When the NSA prohibits billing a patient for services, billers must be clear about the services they can bill directly to the patient and those that they cannot.

Under the NSA, uninsured patients must be given a good faith estimate of the cost of medical services. Billers will need to keep that estimate in mind to avoid preparing bills that substantially exceed the estimate unless the excess billing is justified.

Automation and Billing Software

Healthcare providers continue to experiment with automation in all phases of the medical industry. They rely on technology to improve diagnoses and to make correct judgments about treatment. Providers hope that billing automation will reduce insurance claim denials and produce billings more efficiently.

Just as computers are not ready to replace doctors, billing automation cannot remove qualified billers and coders from the billing equation. Software is only as smart as the human who operates it. Still, improvements in billing software should help reduce human error in medical billing.

“Automating the revenue cycle” has become an industry buzz phrase. Companies that offer “automation solutions” to the medical industry promise to increase efficiency, reduce costs, and minimize errors. There is no doubt that, over time, technology will help integrate processes from patient registration and medical records management to coding and insurance claims submission. Each process is complex, however, and seamless integration is difficult to achieve.

Medical billing services are often challenged to find software that will serve the needs of multiple clients. Different providers keep records in different ways. Some are in digital form and online. Some involve a physician making notes with pen and ink. Billing companies need to work with each provider to find technological and human solutions that maximize efficiency and reliability while minimizing errors and cost. While those solutions continue to evolve from year to year, medical billing services need to keep their finger on the pulse of automation regarding every aspect of medical services delivery and revenue management.

Changes in ACA

Efforts at healthcare reform bring changes to health insurance every year. Unfortunately, different policy makers have different ideas about what “reform” should entail, making it difficult to predict how the health insurance industry will operate from year to year.

Most rules governing the Affordable Care Act (ACA) remain in effect in 2022. The American Rescue Plan, legislation that responded to the pandemic, increased subsidies for insurance premiums while making subsidies available to millions of Americans who previously did not qualify for them. The income cap for subsidy eligibility has been eliminated through the end of 2022.

The Build Back Better plan would extend subsidies for individuals who received unemployment compensation through 2025. Those subsidies expired at the end of 2021. While the House passed a version of the plan that extends the subsidies, whether the Senate will do so is unclear.

Insurance premium subsidies are important to the medical industry, as are limits on out-of-pocket expenses for essential medical services covered by ACA-compliant plans. That limit increased to $8,700 for 2022. When more people and services are covered by insurance, it becomes more likely that healthcare providers will maximize their revenues.

How Does the New Surprise Billing Rule Affect a Medical Billing Company?

Mon, 24 Jan 2022 05:48:00 GMT

In life, there are good surprises and bad surprises. In medical billing , bad surprises tend to prevail. Historically, one of the biggest surprises has been unexpected out-of-network charges.

Surprise billing is most frequent in the context of emergency room charges. Patients who choose to be treated in an in-network facility expect their treatment to be covered by insurance. They often fail to realize, however, that their treatment may include ancillary services by out-of-network providers that are not covered by their insurance plan.

Examples of ancillary services include services provided by anesthesiologists, radiologists, and critical care physicians. Since those specialists provide services within a covered facility, patients often expect their services to be covered by their insurance. Patients are often shocked when they are billed for services delivered by out-of-network providers within a network facility.

Even if an insurance plan covers the ancillary service, it might only pay the rate that the plan pays to in-network providers. Service providers who want to collect their full rate might bill the patient for the difference. Some states prohibit “balance billing,” but many state legislatures follow the lead of medical industry lobbyists and condemn pro-patient legislation as “anti-business regulation.”

Patients confronting a medical emergency have little opportunity to protect themselves from surprise billing. They rarely have time to ask whether each service they receive is covered by their insurance plan. Nor are they in a position to search for more affordable providers. When life and health are on the line in an emergency, patients take what they are offered.

No Surprises Act

The No Surprises Act took effect on January 1, 2022. The Act is intended to eliminate some of the most common medical billing surprises. The Act protects patients who have individual or group health insurance when they receive:

1. most emergency services;
2. non-emergency services from out-of-network providers at in-network facilities; and
3. services from out-of-network air ambulance service providers.

Medicare and Medicaid patients are already protected from surprise billing. The No Surprises Act provides a measure of similar protection to consumer who have private insurance. The law covers most consumers who receive group insurance from an employer, consumers who purchase insurance from a Health Insurance Marketplace, and consumers who purchase insurance directly from an insurance company.

For insured patients, the Act:

1. bans surprise uninsured bills for most emergency services, including billings from out-of-network providers without the patient’s prior authorization);
2. bans out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services;
3. bans balance billing, in the absence of consent by the patient, for certain services (including anesthesiology or radiology) furnished by out-of-network providers during a patient’s visit to an in-network facility; and
4. requires healthcare providers and facilities to give patients a notice explaining the applicable billing protections and who to contact if a patient suspects that a provider or facility violated the protections.

The Act generally requires the patient’s own insurance plan to cover emergency services wherever they are provided, subject to the patient’s usual co-pay requirements. The protection applies to true emergency services, not to a patient’s decision to seek non-emergency treatment in an emergency room.

The Act also prohibits providers from billing for out-of-network services that are provided within a network facility unless the provider has first explained that the service is not covered by insurance and obtained the patient’s consent to incur that expense.

When the No Surprises Act conflicts with state law, the better law controls. In other words, if a state law provides more protection than the No Surprises Act, the patient receives the protection of the state law. The No Surprises Act describes the minimum protections that patients must receive, while placing no ceiling on the protections that states can offer.

Uninsured Patients

Patients who do not have insurance also benefit from the No Surprises Act. Before providing services to an uninsured patient, a healthcare provider must give the patient a good faith estimate of the cost of the services. The good faith estimate requirement also applies to insured patients who are not using their insurance, perhaps because they are receiving services that are not covered by their insurance plan.

The good faith estimate requirement does not necessarily prevent the provider from charging more than the estimate. However, if the charge exceeds the estimate by more than $400, the patient has the right to dispute the bill, provided the dispute is filed within 120 days of the billing date.

The dispute process uses a third-party arbitrator to review the good faith estimate, final bill, and any justification submitted by the provider for the excess charge. The consumer must be a non-refundable $25 administrative fee to initiate the dispute resolution process. If the arbitrator decides in the patient’s favor, the $25 fee is deducted from the bill.

While the dispute resolution process is pending, the provider cannot attempt to collect the bill. The provider cannot refer or threaten to refer the bill for collection and no lawsuit may be filed to collect it. Nor may late charges be assessed.

Medical Billing Disputes

In addition to departures from good faith estimates for uninsured services, patients may dispute billings for emergency services or out-of-network services that should have been provided pursuant to the No Surprises Act. The dispute mechanism is described in the patient’s insurance policy or plan documents. It may be described as a right to “appeal” a charge. Denial of payment should be accompanied by a notice that explains the insurer’s external review process.

Providers also have arbitration rights under the No Surprises Act. When an out-of-network provider submits a billing to an insurer that is covered by the Act, the insurer must decide how much of the bill it will pay. If it pays less than the billed amount, the provider can submit the dispute for arbitration. Both the out-of-network provider and the insurer make a “best offer” and the arbitrator decides which offer to accept. The arbitrator makes that decision by taking into consideration several factors, including the health insurer’s historical median in-network rate for similar services.

New PCM Codes for Medical Billing and Coding Services in 2022

Mon, 17 Jan 2022 08:55:00 GMT

The Centers for Medicare and Medicaid Services (CMS) has enormous influence in the field of medical billing. That isn’t surprising, given the importance of Medicare and Medicaid billings to physician revenue. When CMS decrees that it will only pay bills that meet a specified standard, physicians quickly adopt that standard.

In 2020, CMS adopted a program that it called principal care management (PCM) . The program’s underlying premise is that primary care physicians typically manage the overall care of their patients, while specialists typically manage specific chronic health conditions (such as cancer treatment).

When specialists manage a single chronic health condition, it may be more efficient and less costly for them to follow patients and manage their care without requiring each contact between physician and patient, or staff and patient, to be conducted face to face. The PCM program allows physicians who manage a single chronic condition to be reimbursed for those remote services.

After monitoring the PCM program for two years, the CMS determined that the program is valuable but underutilized. In an effort to give physicians a greater incentive to implement a PCM program, the CMS adopted four new CPT billing codes in 2022. Those codes give physicians more opportunity to bill for PCM services.

What Is Principal Care Management?

The CMS intended PCM to improve the care of patients who suffer from chronic health conditions. Examples of chronic diseases include cancer, heart disease, stroke, diabetes, and Alzheimer’s.

Before it created PCM, the CMS-approved billing Medicare or Medicaid for care coordination services provided outside of regular office visits for patients who had more than one chronic condition. That program, known as Chronic Care Management (CCM), allowed medical practices to bill for clinical staff time that is devoted to treating the patient outside of face-to-face contact with a healthcare provider. The staff member who provides the remote treatment must act under the direction of a physician or qualified health care professional. Sessions must last at least 20 minutes to be billable.

The CCM program is limited to patients who have two or more chronic health conditions. The PCM program is similar to CCM but covers reimbursement for out-of-office services provided to patients who have only one chronic health condition. It also overs reimbursement for out-of-office treatment of only a single chronic health condition in patients who suffer from multiple chronic health conditions. One difference between the programs is that PCM only reimburses out-of-office services that last 30 minutes or more.

The goal of both PCM and CCM is to stabilize chronic conditions more quickly so that patients can return to their primary care physician for management of their overall care. Health care costs are generally reduced when health care can be managed by a primary care physician rather than a specialist.

From the patient’s perspective, having regular sessions with physicians and staff members outside of office visits is convenient and reassuring. Patients report that they feel safe and more valued when they are in regular contact with medical staff.

CPT Codes for PCM

Uniform billing systems make it possible for private insurers and CMS to understand exactly what service the provider delivered. To that end, American Medical Association created and maintains thousands of codes — known as Current Procedural Terminology (CPT) codes — that describe each service or procedure for which a healthcare provider might bill. The CMS incorporated CPT codes into its own coding system, the Healthcare Common Procedure Coding System (HCPCS).

In 2020, CMS approved two new CPT codes to support PCM. One code was approved to describe at least 30 minutes of physician provider time with a patient. The other was used to describe at least 30 minutes of staff provider time.

To use the codes, the practice was required to provide comprehensive case management services to a patient who has a qualifying chronic health condition. A qualifying complex chronic condition must be expected to last at least 3 months and must place the patient at risk of hospitalization unless it already caused the patient’s hospitalization.

The qualifying condition must require and be the focus of a disease-specific case management plan. The condition must either require frequent adjustment of a medication regimen or must require unusually complex management because of comorbidities.

The billing code for clinical staff time may be used only when the staff member’s time is directed by a physician or other qualified healthcare professionals. The CMS did not allow both the physician CPT code and the staff CPT code to be billed in the same month.

Changes to CPT Codes in 2022

With two years of experience, the CMS determined that PCM services were undervalued. It raised the authorized reimbursement rates in 2022. It also scrapped the two CPT codes that it implemented in 2020. It replaced those codes with four codes that closely track the codes used for CCM billing.

The new PCM codes apply to patients who have a single high-risk disease or complex chronic condition. The codes apply to the following services:

As the codes apply on a monthly basis, the 99424 and 99426 codes may only be billed once per month. Each additional 30-minute increment of services during that month must be billed using the 99425 or 99427 codes, depending on whether services were provided by the physician or staff.

What Are CPT Code Modifiers? How Are They Used?

Mon, 10 Jan 2022 06:41:00 GMT

Medical coding is complex. Medical coders follow guidelines created by the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) to assign codes to the services and procedures performed by healthcare providers. Insurance companies and the government agencies that administer Medicare and Medicaid payments rely on those codes to determine the payment that should be made for each procedure or service. Incorrect codes lead to incorrect payments.

The AMA’s standardized coding system assigns a 5-digit code to each medical service or procedure. Sometimes, however, the 5-digit code doesn’t tell the whole story. It may be necessary to add another code to provide additional information about the procedure. Those additions to the code are called code modifiers.

Some code modifiers affect billings. Others do not. Using the correct modifier assures that billing records are accurate and is often an essential assurance that a patient is not being overbilled.

CPT Codes

The AMA’s coding system is known as the Current Procedural Terminology (CPT) system. The AMA’s CPT codes are incorporated into the Healthcare Common Procedure Coding System (HCPCS) that the CMS requires providers to use when billing for services that are covered by Medicare or Medicaid.

Five-digit CPT codes are divided into six categories: Evaluation and Management Services (such as office visits), Anesthesiology, Surgery, Radiology, Pathology/Laboratory Services, and a catchall Medical Services category that covers ophthalmology, vaccinations, and other services that aren’t included in the Evaluation and Management Services category.

Codes play a vital role in billing, but they are also used for other purposes. While thousands of Category I codes describe medical procedures and services, Category II codes are used to track information about patients. Researchers also use billing codes to analyze trends in the delivery of medical services in various regions of the country.

While CPT codes provide the information that insurers need to understand the services for which they are being billed, the code alone might not provide all the information that a person reading the billing might need. When a CPT code doesn’t tell the whole story, billers add clarity by attaching a CPT code modifier.

CPT Code Modifiers

Code modifiers help healthcare providers create accurate and detailed billings. While not all modifiers translate into charges for services, they all provide useful information. The correct use of modifiers helps healthcare providers comply with regulations and avoid accusations of fraud.

A CPT code may be followed by more than one modifier. For example, a “functional” modifier might be added that affects billing, while an “informational” modifier might simply provide additional information about the procedure. Billers place functional modifiers before informational modifiers because payers might only look at the first one or two modifiers when deciding how much to pay for a service or procedure.

One in ten billing errors involve the use of code modifiers. Understanding how modifiers work is essential to the preparation of accurate billings.

Modifiers consist of two digits. They can be letters or numbers or one of each. The modifier is appended to the 5-digit CPT code. The modifier does not change the CPT code but calls attention to special circumstances associated with the service or procedure that the patient received.

The most common examples of circumstances that require a modifier are:

1. A service or procedure has both a professional and technical component, but only one component is applicable.
2. A service or procedure was performed by more than one physician or in more than one location.
3. The time spent to perform a service or procedure was longer or shorter than the CPT code would otherwise indicate.
4. Only part of a service was performed.
5. An adjunctive service was performed.
6. A bilateral procedure was performed.
7. A service or procedure was performed more than once.
8. Unusual events occurred during a procedure or service.

Modifiers are based on medical records or other medical documentation. A modifier should not be appended to a CPT code unless facts that support the modifier can be located in the medical documentation. Adding a modifier that is not supported by medical records can be a sign of fraud or overbilling.

Common Examples of CPT Code Modifiers

Certain Evaluation and Management (E/M) CPT codes are assigned according to the level of service provided. The highest level service generally takes the most amount of time. When the highest level CPT code does not reflect the full time that the provider spent to deliver the service, the code modifier 21 may be added to indicate that services were prolonged. In some cases, it may be more appropriate to use a 5-digit “prolonged services” CPT code rather than adding a modifier.

The 21 modifier should not be routinely added to E/M codes and should only be added to the highest level codes. The frequent addition of a 21 modifier to a billing or series of billings may be a red flag that will alert auditors or medical billing experts to the possibility of fraud.

Billers add 25 as a modifier when the patient received an additional service that was separate or distinct from another procedure that is being billed. For example, when a patient comes in for an in-person dialysis but receives a separate examination and diagnosis of an unrelated problem, the 25 modifier might be appropriate to make clear that the separate examination was unrelated to the dialysis.

The modifier 22 is added to CPT codes when a procedure took longer than usual to perform and when no other CPT code addresses the prolonged nature of the service. Unusual blood loss, hemorrhage, or unexpected complications during surgery might justify use of the 22 modifier, assuming that the medical records reflect the unusual circumstances.

The modifier 52 is used to reflect reduced services. For example, the CPT code for a comprehensive x-ray might be modified when only a limited comparative x-ray is performed. When a surgeon decides to discontinue surgery based on unexpected findings that suggest a threat to the patient, the modifier 52 will indicate that the procedure took less time than a completed surgery would have taken.

Payers may or may not take modifiers into account when they pay for services. Accurate billings nevertheless depend upon the accurate use of modifiers. While the rules governing modifiers are complex, medical billing experts understand the importance of following those rules with precision.

What Are the Rules for Billing Remote Therapeutic Monitoring Codes?

Mon, 03 Jan 2022 06:40:00 GMT

Remote monitoring of patients is a way for healthcare providers to access information about patients who are not in the provider’s presence. Healthcare providers gather data from their patients without requiring the patient to visit a doctor’s office and submit it to on-site testing.

Remote patient monitoring (RPM) is an established part of medical practice and billing. Billings for RPM have generally been limited to the collection and monitoring of specific data using medical devices, followed by virtual consultations with patients who are being monitored.

For example, patients who measure their blood pressure, pulse rate, or blood glucose at home use devices that transmit that information to their doctor. If the data alerts the doctor to an emerging or urgent healthcare problem, the doctor can contact the patient with advice or to schedule an office visit.

Remote monitoring of patients offers the promise of better healthcare at a reduced cost. Because the patient does not need to meet the doctor in person, RPM results in fewer office visits. Virtual care management meetings allow the patient to receive medical advice from the comfort of his or her own home. Staffing needs are reduced because a provider can manage health care without the need for staff to meet with the patient, bring the patient to an examination room, and juggle patients because of missed or late appointments.

What Are the CPT Codes for RPM?

For some time, Medicare and private insurance companies have offered reimbursement to healthcare providers who implement a system for remote health monitoring of their patients. To assure that physicians are reimbursed for the time they spend reviewing data that was gathered remotely, the government agency that handles Medicare and Medicaid reimbursement — the Centers for Medicare & Medicaid Services (CMS) — established CPT codes for remote patient monitoring.

The American Medical Association , together with CMS, creates and maintains 5-digit codes that describe each service or procedure for which a healthcare provider might bill. Insurance companies and government agencies rely on those codes to determine the rate of reimbursement the provider will receive for each billed procedure or service.

The CPT codes for RPM typically cover monitoring of physiological measurements, including blood pressure, pulse oximetry, and respiratory flow rate. One billing code applies to a patient’s initial entry into an RPM program. The code covers the time spent demonstrating the data collection device(s) to the patient and explaining how often the patient should take a measurement.

A second CPT code covers 30 days of monitoring data, provided the patient takes measurements at least 16 times during the 30-day period. The code also covers the physician’s amortized cost of the data collection equipment that the physician supplies to the patient.

A third CPT code covers 20 minutes of remote contact with a patient by the provider, including doctors and care managers, to discuss healthcare management based on the collected data. That code is billable monthly. A fourth CPT code covers additional time spent in virtual interactive patient care during the month in 20-minute increments.

What is Remote Therapeutic Monitoring?

The success of remote monitoring persuaded CMS to expand reimbursement to monitoring of data that was not covered by its initial approval of CPT codes for RPM. The CMS has authorized a new set of CPT codes that govern expanded services that healthcare providers offer remotely.

Remote therapeutic monitoring (RTM) codes cover services that are similar to RPM but include a broader range of health conditions. At the moment, RTM includes monitoring of respiratory and musculoskeletal conditions.

The CMS rules governing reimbursement of RTM differ from RPM rules with regard to the kind of data that the provider monitors and the ways in which data is collected. The rules also differ with regard to the kinds of providers who are eligible for reimbursement.

Like RPM, data collected by medical devices is a part of RTM. For example, a physician may provide an inhaler to a patient with a pulmonary condition (such as COPD) that monitors when and how often during the day the patient uses the inhaler, how many puffs/doses the patient uses each time, and the pollen count and environmental factors at the time the patient uses the inhaler. The physician would use that information to determine the effectiveness of treatment, the environmental conditions that appear to trigger respiratory distress, and the possible deterioration of the patient’s condition.

However, RTM also includes certain self-reported data. While coverage for RPM depends on the use of medical devices that record and upload the patient’s physiological data, some RTM data can be self-reported, entered manually into a device, and uploaded by the patient.

The new rules allow reporting of data that can’t be recorded by a device, such as pain levels and reactions to medication. At this point, the list of data that can be collected appears to be illustrative rather than exhaustive. It is not entirely clear how much therapeutic data (i.e., data that is not measured by a medical device) can be included in reimbursable RTM data monitoring.

The other key difference between RTM and RPM is that RTM is classified as general medicine, while RPM is classified as Evaluation and Management services. Classifying RTM as general medicine makes it possible for additional Qualified Health Care Professionals (QHCPs) to apply for reimbursement for remote monitoring services. The CMS anticipates that most billings using RTM codes will be for services provided by nurses and physical therapists.

What Are CPT Codes for RTM?

The CMS has authorized five new CPT codes to describe and seek reimbursement for RTM procedures. Those codes will go into effect on January 1, 2022.

To some extent, the codes parallel RPM codes. The first code addresses the initial set-up of RPM, including instructions on when and how to record data and how to upload the data to the provider’s system.

The next two codes address monitoring during a 30-day period. Monitoring includes a review of recorded data as well as the patient’s adherence and response to therapy. One code applies to the monitoring of the respiratory system and the other applies to the monitoring of the musculoskeletal system.

The last two codes apply to interactive communications with the patient by a physician or other QHCP. The first code describes a 20-minute session while the second code applies to each additional 20-minute increment.

Why Are Medical Billing Expert Opinions Admissible as Evidence?

Mon, 27 Dec 2021 06:22:00 GMT

Lawyers use medical billing experts in a variety of legal proceedings. In personal injury cases, plaintiffs must typically prove that the medical expenses they seek to recover are reasonable. Defendants, on the other hand, often challenge the reasonableness of medical bills that appear to be inflated. Medical billing experts can assess bills for either a plaintiff or a defendant to offer an objective opinion whether the bill reflects procedures that were actually provided, whether the billing codes that determine charges are accurate, and whether the billing is consistent with the usual, customary, and reasonable charges within the same geographic area for the same services.

In false claim proceedings, medical billing experts help whistleblowers establish that a medical provider overbilled Medicare, Medicaid, or another government agency for medical services. Lawyers use their expert analysis to establish a pattern of using CPT codes that do not reflect the actual procedures and services that were rendered. Lawyers can establish an inference of fraud based on patterns of overbilling that medical billing experts document.

In medical malpractice cases, medical billing experts can uncover evidence that medical records were changed in an effort to cover up a health care provider’s mistake. It is easier to alter a medical record than it is to change a billing that has already been submitted to an insurer.

In all of those cases, and in any other case when medical billings may be introduced into evidence, medical billing experts can provide vital evidence. Fortunately, courts have routinely agreed that medical billing experts satisfy the evidentiary standard that governs the admission of expert testimony.

Standards of Expert Evidence Admissibility

The Federal Rules of Evidence and every state evidence code permit expert testimony while placing limitations on its admissibility. All jurisdictions agree that expert testimony is only admissible if it helps the jury understand relevant facts. If ordinary people are capable of understanding the evidence, expert testimony is not necessary.

All jurisdictions also agree that expert witnesses must be qualified to give expert testimony. Experts can be qualified by virtue of their education, training, and experience.

In the federal system, expert testimony must also satisfy the Daubert standard. Federal judges determine whether the proposed testimony is sufficiently reliable to warrant consideration by a jury. Reliability is a function of: (1) the expert’s consideration of sufficient facts to form an opinion, (2) the expert’s use of a reliable methodology to form opinions, and (3) the expert’s application of the methodology to the facts in a reliable way.

Most states have adopted some form of the Daubert standard, although many have merged the standard with evidentiary standards that predated Daubert . Although the Daubert standard applies to both scientific evidence and to expert evidence that is not based on science, judges have been noticeably more stringent in applying Daubert to science-based testimony.

Before Daubert became the reigning standard of admissibility, federal courts and most states followed the Frye standard. That standard is still the law in some states. It allows the admission of expert testimony if the expert’s methods are generally accepted by other experts in the same field. Other states have adopted a hybrid of Daubert and Frye or have taken their own unique approach to the admission of expert testimony.

Billing Experts Have Unique Knowledge

Courts routinely find that medical billing experts have unique knowledge that most jurors lack. The charges for medical services depend on the Current Procedural Terminology (CPT) code that the biller assigned to each billed service or procedure. Assigning the wrong code will often result in an overbilling.

For example, medical billing experts review medical bills for upcoding. When medical records describe a specific medical procedure but the billing shows a CPT code for a more complex (and thus more expensive) procedure, the patient will be overbilled. The problem of upcoding, whether deliberate or accidental, is common in medical billings. An ordinary juror, however, lacks an understanding of the thousands of CPT codes that medical billers use to identify procedures and services. Medical billing experts are familiar with medical procedures and with the specific CPT code that should be applied to each medical procedure or service that appears on a medical bill.

Another common billing error is known as unbundling. Doctors sometimes perform more than one procedure at the same time. When those procedures are performed separately, the total time it takes to perform them is greater than when they are performed together. Consequently, using the CPT code for a set of “bundled” procedures will result in a lower price than using separate CPT codes for each “unbundled” procedure. Medical billing experts are trained to detect unbundling and to identify the erroneous use of multiple CPT codes when bundled procedures should be covered by a single CPT code.

Billing Experts Are Qualified to Render Opinions

Medical billing experts are trained in medical terminology. They have a basic understanding of anatomy, physiology, and pathology. They are qualified to read medical records and to identify specific medical services and procedures that were delivered to patients.

Medical billing experts are also trained to identify the correct and incorrect use of CPT codes. In addition, they are familiar with specialized databases that record the prices that physicians in a community charge for medical services. That specialized training qualifies medical billing experts to express opinions about the accuracy and reasonableness of medical billings.

Medical Billing Experts Use Reliable Methodologies

Reliability is the key to admissibility in jurisdictions that rely on Daubert . Medical billing experts use methodologies that are commonly accepted within their field of expertise. They thus satisfy both the Frye standard and one of the measures of reliability that Daubert courts employ.

The methodology requires billing experts to gather adequate facts from medical records, to compare those records to medical billings, and to determine whether the medical procedures and services provided match the CPT codes in the medical billings. The methodology then requires billing experts to use databases that are standard in the field and to compare the doctor’s billing for services to usual and customary charges to assess reasonableness. Since medical billing experts are able to explain why their methodology produces reliable results, courts routinely allow medical billing experts to offer opinions about the accuracy and reasonableness of medical bills.

How Does Insurance Affect the Reasonableness of Medical Bills?

Mon, 20 Dec 2021 13:09:00 GMT

Accident victims who have health insurance typically submit their medical bills to their insurers for payment. Depending on the nature of their insurance plan, the victims will usually pay a co-pay or a deductible. The insurance company may or may not pay the rest of the bill, depending on the terms of the insurance policy and on the insurer’s view of whether the expenses are reasonable.

When an accident victim sues a negligent party for causing the victim’s injuries, the victim will typically seek recovery of the victim’s medical expenses in addition to other damages. The amount the victim will recover may be affected by whether the victim was insured and, if so, the amount of medical expenses paid by the insurance company.

While states follow different rules, they generally limit the plaintiff’s recovery to medical expenses that are reasonable and necessary. In some states, expenses are presumed to be reasonable to the extent that they were paid. An insurance company’s payment of medical expenses may therefore be evidence of reasonableness on the theory that rational people will not pay an unreasonable bill.

The insurance company may have a subrogation interest in the plaintiff’s recovery to the extent of the bill payment. If the plaintiff only recovers medical expenses that were covered by insurance, the plaintiff might not receive any medical expense recovery unless the plaintiff proves that medical expenses not paid by insurance were reasonable and necessary. The unpaid portion of the bill is not presumed reasonable, leaving it to the accident victim to introduce expert testimony (usually provided by a medical billing expert) to obtain a full recovery.

The Collateral Source Rule Controversy

Medical care providers often make an agreement with a health insurer to accept the insurance company’s payment of an insured’s medical bill as full payment, even if the payment was for less than the billed amount. When the accident victim is under no obligation to pay the balance of a bill that has been settled by an insurance company, most states allow the injury victim to recover the full amount of the bill from the negligent party.

The prevailing understanding of the “collateral source rule” is that “damages may not be diminished or mitigated on account of payments received by plaintiff from a source other than the defendant.” Thus, if an accident victim incurred a $10,000 medical bill and the victim’s health insurer accepted $7,000 as full payment pursuant to a preexisting agreement with the insurer, the fact that $7,000 of the $10,000 was paid does not necessarily extinguish liability for payment of the full $10,000.

After all, the accident victim paid for health insurance. She should not be penalized by limiting her recovery when an uninsured accident victim would be able to recover the full $10,000.

California has taken a different approach. In 2011, the California Supreme Court decided that the state’s collateral source rule allows the injury victim to recover medical expenses for which the victim is actually liable, even if insurance paid those expenses. However, if the health insurer has a preexisting agreement with the medical provider that extinguishes the victim’s responsibility for paying the balance of a bill, California’s version of the collateral source rule does not allow the victim to recover the unpaid portion of the bill.

Since the victim is not liable for payment of the part of the bill that the insurer does not pay, the California Supreme Court decided that those expenses “do not represent an economic loss for the plaintiff.” That’s true, but the premiums the insured paid for the insurance that covered the bill do represent an economic loss.

Plaintiffs’ lawyers question the fairness of allowing an uninsured victim to recover the full bill while a victim who had the foresight or means to purchase insurance can only recover the amount paid by the insurer. Insurance defense lawyers question the fairness of making a defendant (or the defendant’s insurer) reimburse a plaintiff for medical bills that the plaintiff will never be required to pay.

Collateral Source Rule Trends

Most courts have not been persuaded by the California interpretation of the collateral source rule. Speaking to Nevada law, a federal district court recognized that the California decision is “squarely at odds with the collateral source rule, which utterly disregards the amount of money a tort victim is actually made to pay to remedy his injuries, in favor of awarding the reasonable cost of ameliorating the injuries.” Most courts have agreed that California gives a windfall to defendants who happen to injure an insured party.

On the other hand, some state legislatures have agreed with the insurance industry that it is unfair to give a windfall to plaintiffs by allowing them to be reimbursed for medical bills they will not need to pay. Some state laws allow the jury to award full medical expenses as damages and then require the judge to deduct amounts that were paid by insurance unless the insurer is subrogated. Some state laws apply the collateral source rule in most tort actions but not in medical malpractice cases.

States that require judges to reduce damages after a verdict is returned to reflect collateral payments will generally allow the jury to consider the full bill. Those courts recognize that the amount of a bill is relevant evidence of the injury a plaintiff received. Since juries tend to base pain and suffering damages on a multiplier of medical expenses, proving the reasonableness of medical expenses can be important even if the judge might later reduce the verdict by deducting payments made by collateral sources.

Proof of Reasonableness

Medical billing experts analyze medical bills and provide expert opinions about their reasonableness. That analysis considers whether the biller followed appropriate standards. Unbundling charges for separate procedures that should have been billed as a single procedure is the kind of error that inflates medical bills. Using the wrong CPT code to describe the procedures performed, or billing for procedures that were never performed, are additional examples.

After determining whether the billing is accurate, medical billing experts determine whether the billing reflects usual, customary, and reasonable charges within the community where the services were provided. Billing experts rely on comprehensive databases of actual charges for the same services to determine whether medical bills are reasonable. Testimony about reasonableness for either the plaintiff or the defendant can have a significant impact on jury verdicts.

Just How Good Is Your Medical Billing Company?

Mon, 06 Dec 2021 10:39:00 GMT

Clinics, hospitals, medical practices, and other organizations that provide medical services often outsource their medical billing. Rather than adding the costs of a medical billing department to their business expenses, they take advantage of efficiencies that can be realized by hiring a company that handles billing for multiple clients. Removing billing staff from their payroll helps healthcare providers focus on what they do best — delivering medical services to their patients.

Outsourcing avoids the headaches caused by employee turnover and the risk of hiring untrained staff. Staff shortages and slow learning curves can cause delays in billing and lead to cashflow problems. Outsourcing medical billing shifts responsibility for professional and timely bill preparation to a company that devotes all its resources to medical billing.

Some billing companies are better than others. When a medical practice decides to enter into a professional relationship with a medical billing company , how can it know that it made the right choice? Here are some important questions that will help a healthcare organization assess the quality of its medical billing company.

How Does the Company Protect Confidential Data?

Billing companies translate medical records into billings. The patient information in medical records is confidential. A billing company that is not HIPAA complaint places healthcare providers at risk.

While the company might access medical records online, it is important to know how the company protects passwords, emails, and downloaded data. Who has access to passwords and how are passwords stored?

If the company keeps protected health information on its own servers, the healthcare provider should understand the company’s policy regarding the destruction of that information. The provider should understand exactly how confidential data is overwritten so that it can’t be stolen by someone who gains unauthorized access.

How Easily Can You Access Information About Your Insurance Claims?

After medical billing companies prepare bills, they submit the bills to insurance companies, Medicare, or other sources of payment. Healthcare providers have a keen interest in tracking the status of those claims.

Medical practices increasingly use electronic medical records (EMR) or electronic health records (EHR) to keep track of patient data. Ideally, the software will sync with a medical billing system, allowing the practice to determine the status of billing and claims payments for each patient.

Some billers use their own software rather than the practice’s EHR or EMR software to prepare bills and submit claims. While there is nothing inherently wrong with wanting to use a single software system while preparing bills for multiple clients, healthcare providers may have difficulty accessing the status of their claims. A billing company might be hiding its lax approach to claims submission and collection by failing to make that information readily available to its clients.

How Timely and Useful Are the Biller’s Monthly Reports?

Ideally, a medical practice should be able to access its billings and determine insurance claim status in real time, either by running reports on its own software or by having access to the biller’s system. When that doesn’t happen, the biller should at least provide monthly reports each month that provide details of bills submitted, claims paid, and claims pending, with granular information about the failure of an insurer to pay each unpaid claim.

Even when the practice has access to that information in real time, monthly reports allow the practice to determine which areas of the practice are performing well and which are failing to meet established benchmarks. Monthly reports help medical practices fix problems and recalibrate expectations.

How Qualified Are the Company’s Staff Members?

Medical billing services should be staffed with billers and coders who have the education and training that allows them to do their work professionally. They should be fully trained to assign the correct Current Procedural Terminology (CPT) to procedures and services, accurate diagnostic (ICD) codes to a physician’s medical diagnosis, and Healthcare Common Procedure Coding System (HCPCS) codes to assure reimbursement by Medicare and Medicaid for supplies and procedures that aren’t covered by CPT codes.

Medical billers and coders need to have a basic understanding of anatomy, physiology, and medical procedures so that they can understand medical records and differentiate one procedure from another. They need to be trained to avoid upcoding and unbundling , two errors that will delay payment of claims and may lead to accusations of fraud.

Certified medical coders have completed a certification exam that requires them to demonstrate proficiency in CPT, HCPCS, and ICD codes. A company that focuses its hiring on certified medical coders or on coders with years of experience in the field is in the best position to deliver reliable results.

How Quickly Does the Company Respond to Concerns?

Patients, insurers, and Medicare auditors are among the persons who raise questions about medical bills. Those questions are usually directed to the medical practice that provided the billed services. Medical professionals need quick responses to those questions to satisfy patients, insurance companies, and the government.

A good billing company should have the resources to answer questions promptly. A company that responds “We’re busy right now, we’ll have to research the question and get back to you in a few days” puts a medical services provider at risk of losing credibility. An efficient and profitable medical practice depends on its billing company to provide fast answers to billing questions. Delays are a sign of a billing company that is trying to save money by hiring an inadequate number of qualified staff members. Delay could also signal errors that the billing company is trying to conceal.

Does the Billing Company Have a Denial Management Team?

Some claims are denied because the billing company made an error. When that happens, the company should be able to identify and correct the error immediately.

Other claims are denied because the insurer has an issue with the healthcare provider. The insurer might contend that billed procedures were unnecessary or that the provided procedures are not covered by insurance. A denial management team can work as an intermediary between the insurer and the medical practice to resolve concerns efficiently and productively.

Can You Do Medical Billing and Coding at Home?

Mon, 29 Nov 2021 12:29:00 GMT

A career in medical billing and coding is an attractive option for individuals who want some assurance that their job isn’t likely to disappear in the foreseeable future. Many office jobs, including secretarial and office administrator positions, are less plentiful than they were in years past. The ability of professionals to use technology to prepare documents and to store data on a hard drive without the assistance of typists, clerks, and secretaries has made it more difficult for support workers to find traditional office employment.

Medical billers and coders , on the other hand, are working in a growing field. The demand for healthcare services will continue to increase as the national population continues to age. According to the Bureau of Labor, jobs for medical support personnel, including medical billers and coders, will increase by 9% to 11% over the next ten years. Jobs for general office clerks are expected to decline by 2% in the same period.

Medical Billing and Coding Employment

The demand for medical billers and coders cannot be met by workers who have general clerking or secretarial skills. The job requires specialized knowledge that can only be acquired through education, training, and experience.

Medical billers and coders must be familiar with medical terminology. Medical billers and coders typically gain or refresh their knowledge of medical terminology by taking classes.

The most specialized aspect of medical billing and coding involves a mastery of Current Procedural Terminology (CPT) codes. The American Medical Association had developed more than 10,000 CPT codes to identify services and procedures that doctors provide to their patients. The codes describe different kinds of office visits and examinations, surgical procedures, the administration of anesthesia, lab tests, and other services for which healthcare providers bill.

Medical bills include CPT codes so that insurance companies can make the correct payment for services rendered by a healthcare provider. Insurance companies, the federal agency that pays for Medicare, and state agencies that pay for Medicaid and other medical benefits all require that medical bills identify services and procedures by CPT codes.

Medical billers and coders take specialized classes to help them understand the complex principles that underlie the selection of a correct CPT code. Choosing the correct code is essential to assure that patients are not billed too much or too little for a procedure. Mistakes generally cause insurance companies to reject billings and will delay a provider’s payment until the billing is revised. Coding errors may also cause billings to be challenged in court.

Medical billers and coders base their choice of the correct CPT code on information they find in medical records. Their classroom education prepares them to understand those records and to prepare medical bills that reflect accurate CPT codes. They also learn about a separate code that reflects the patient’s medical diagnosis. Medical coders and billers become proficient in specialized computer software that they will use to prepare medical billings.

Employers and Work Environments

Medical billers and coders are primarily employed in the healthcare industry. They work for hospitals, clinics, urgent care centers, nursing homes, and doctors’ offices. Hospitals alone employ about a third of medical billers and coders, while nearly 20% work for doctors’ offices.

Most healthcare facilities establish a billing department that is separate from the medical records office and nursing stations, but medical billers and coders often interact with other staff if they need assistance understanding specific entries in medical records. Medical billers and coders do not typically interact with patients, although a manager might meet with patients to answer questions about their bills.

Insurance companies also employ medical billers and coders. Insurance companies review bills carefully to determine whether procedures are covered and whether the billing accurately reflects the procedures that were rendered. That review is conducted by medical billers and coders at the request of claims managers. Some companies outsource that review to businesses that offer medical billing review services to the insurance industry. Those businesses are another source of employment for medical billers and coders.

Like insurance companies, government agencies rely on medical billers and coders to review billings to assure that the agency is not being billed in error . Medicare, Medicaid, billings for covered services provided to members of the military and veterans, the State Children’s Health Insurance Program, and Indian Health Services are among the government agencies that employ medical billers and coders. In addition, medical billers and coders are employed to help government agencies compile nationwide or statewide data about medical services.

Legal Services

Medical billing experts help lawyers understand whether medical billings are accurate and whether they reflect the usual, customary, and reasonable charges for services in the community where the services were rendered. Lawyers need that information when they seek or contest reimbursement of medical bills in personal injury and related cases. Medical billing experts also help lawyers prove claims of fraud that are brought by whistleblowers within a doctor’s office. Those cases typically involve deliberate overbilling in claims submitted to Medicare for payment.

Medical billing experts who work for the legal industry are sometimes employed in-house by law firms. It is much more common, however, for lawyers to hire an outside firm of medical billing experts to provide analysis and expert testimony.

Working from Home

The pandemic gave employers an opportunity to experiment with having employees work from home. Many employers found that worker productivity improved when employees did not need to be in the office every day. Since medical records are increasingly maintained in an electronic format, medical billers and coders are often able to access all the material online that they need to work from home.

More traditional employers like to keep employees in the office so they can be supervised. Some employers think that medical billers and coders are more productive when they can speak in person to staff members who can answer questions about medical records. And some doctors and clinics still keep records on paper, which makes them difficult to access from home.

Whether a medical biller or coder can work from home, therefore, depends on the employer. The profession does, however, create opportunities for people with a medical billing and coding background to work as freelancers or independent contractors. Once a medical biller and coder has gained experience and made contacts, it is often possible to work from home by being self-employed.

How Does Someone Become a Medical Biller and Coder?

Mon, 22 Nov 2021 12:48:00 GMT

Medical billing is unlike billing for most professions. A plumbing company’s billing clerk might prepare a bill based on a plumber’s record of time spent on a project and add charges for supplies used in the project. On-the-job training teaches employees how to prepare a bill of that nature.

Medical billing requires specialized knowledge that most clerical positions lack. Gaining that knowledge opens the door to a satisfying career as a medical biller and coder. The Bureau of Labor Statistics expects jobs for clerical support staff for healthcare providers to increase by 11% before 2030. That’s a sharp contrast to most other clerical positions, which are expected to decline because of changes in technology. The growth of the healthcare industry, prompted in part by the nation’s aging population, assures that medical billing and coding specialists will be a vital part of the economy for decades.

What Do Medical Billers and Coders Do?

Unlike plumbers, doctors do not typically charge by the hour. Insurance companies and government agencies that pay for Medicare and Medicaid expect healthcare providers to charge by the service or procedure. They generally pay a set amount for each service or procedure performed.

Since different doctors might use different terminology to describe the same procedures, the medical industry has created standardized codes that identify specific services and procedures. Those codes are developed and maintained by the American Medical Association. More than 10,000 Current Procedural Terminology (CPT) codes identify services and procedures that range from brief office visits to heart bypass operations.

Medical coders identify each specific service or procedure that the patient received. They then match those services and procedures to specific CPT codes. That task is more complex than it might sound. For example, the coder must choose from six different codes that describe heart bypass surgery, depending on the number of coronary bypass grafts that were involved in the operation.

Coders must also keep in mind that the code may differ depending on whether multiple procedures were performed at the same time. Rather than billing each procedure separately (a mistake that is known as “unbundling”), the coder must apply a code that applies when those procedures are performed in the same operation or office visit.

Coders must also use a separate set of codes, known as diagnostic codes or International Classification of Diseases (ICD) codes, to identify each diagnosis that the physician made. Diagnostic codes are developed by the World Health Organization to describe tens of thousands of diseases, injuries, and other health conditions.

What Training or Education Do Medical Billers and Coders Require?

Medical billing and coding experts need to understand the terminology used in the medical profession. They need to interpret medical records so that they can made a precise determination of the services and procedures provided to a patient and of the patient’s specific diagnosis.

Medical billers and coders take classes in medical terminology and learn the fundamentals of anatomy, physiology, and pathology. They take classes in diagnostic coding, CPT coding, and preparation of medical bills. They also take classes that will help them become proficient in specialized computer software used to prepare medical billings.

Medical billers and coders study the process of submitting billings to insurance companies and medical agencies and the requirements that those entities impose as a condition of paying medical bills. They take classes in insurance claims processing and learn about their obligations when billings are challenged. They learn about the various ways that medical records are prepared and stored, either on paper or in electronic databases.

Since some healthcare providers may pressure billing and coding specialists to help them defraud insurance companies or government agencies, students take classes in medical ethics to help them understand their legal obligation to prepare honest bills that are justified by the medical records. Students also study rules and laws governing patient confidentiality, records management, and security procedures to assure that medical records are not inadvertently disclosed without a patient’s consent.

Who Should Pursue a Career in Medical Billing and Coding?

A medical billing and coding specialist must pay close attention to detail. The work cannot be performed successfully by people who become easily distracted or have a short attention span. Medical billing requires intense concentration and a focus on each task that is part of the billing process. It also requires patience and a willingness to double-check work to make sure it is accurate.

Individuals with a nursing background are often attracted to the field of medical billing and coding because they are already familiar with medical terminology. The job is less physically demanding than nursing because it does not require long hours of standing or interaction with difficult patients.

What Careers Are Available to People Who Study Medical Billing and Coding?

The healthcare industry is a primary employer of medical billers and coders. Hospitals, clinics, and private medical offices that deliver medical services in a variety of specialties all employ medical billers and coders.

The insurance industry also employs individuals with a background in medical billing and coding to review medical bills in order to determine whether they should be paid. Government agencies that administer Medicare and Medicaid also employ specialists to determine whether billings satisfy standards that must be met as a condition of payment.

People who are particularly proficient in medical billing and coding may join private firms that provide expert services to lawyers, patients, and others who need to understand whether billings are accurate and reasonable. Medical billing experts help lawyers and their clients detect fraud and identify intentional or inadvertent overbilling.

To collect medical expenses as an element of damages in a trial, injury victims must prove that the bills were reasonable. Medical billing experts develop an understanding of how usual, customary, and reasonable (UCR) charges are determined. They also learn to use specialized databases that help them determine whether particular billings meet the UCR standard. Medical billing experts prepare reports to assist litigation and may testify in depositions or trials for either the plaintiff or defendant when the reasonableness of medical billings is contested.

Medical CPT Codes: What is CPT?

Mon, 15 Nov 2021 08:55:00 GMT

Medical bills are claims for payment for the services provided the healthcare providers. Billings are usually submitted to insurance companies or to government agencies responsible for Medicare and Medicaid. The bills follow formats that insurers and agencies require to understand the services that were provided and the fees that should be paid to the providers.

When a doctor provides a service, a medical coder translates that service into a specific code that describes the service provided. Those codes appear on medical bills.

Medical coders generally assign two kinds of codes. When a physician diagnoses a health condition, the coder assigns a diagnostic code that describes the condition. When a physician provides a service or procedure to a patient, the coder assigns a CPT code that describes the service or procedure.

What is CPT?

Doctors perform a large variety of services for patients. While many other professionals bill by the hour, insurance companies typically pay by the procedure. To standardize payments, insurers and government benefit providers need billings to reflect the precise procedure or service being billed. While that could be accomplished using words, medical billings reduce those words to numerical codes called Current Procedural Terminology (CPT) codes.

The American Medical Association (AMA) developed CPT codes to facilitate billing, but the codes serve other purposes, as well. For example, CPT codes make it possible to gather statistical information about the frequency with which the same procedures are performed in different areas of the country.

The AMA first developed CPT codes in 1966. The AMA has revised and expanded the coding system on several occasions. The Centers for Medicare & Medicaid Services, which oversees the Medicare and Medicaid programs, incorporated the AMA’s CPT codes into its own system, the Healthcare Common Procedure Coding System (HCPCS).

The AMA has established a CPT Editorial Panel to update the CPT coding system based on changes in medical practices, treatment methods, and technologies. The CPT Editorial Panel consists of independent expert volunteers from different sectors of the health care industry. They receive input from physician advisors who are nominated by medical specialty societies.

The AMA’s CPT codes have become the default coding system for medical bills, in part because the government requires CPT codes to be used as part of the HCPCS system for Medicare and Medicaid billing. Most private insurers regard the CPT codes as their preferred coding system for medical billings.

Categories of CPT Codes

The bulk of CPT codes are known as Category I codes. These are 5-digit codes that describe most medical procedures and services.

Category I codes are divided into six sections. The most frequently used CPT codes are found in the Evaluation and Management Services section. These codes describe office visits, examinations, inpatient hospital visits, consultations, emergency department visits, counseling, newborn care, and other patient care services.

Category I codes range from 99091 to 99499. For example, CPT code 99212 refers to an office or outpatient visit with an established patient that takes less than 20 minutes. Different codes for outpatient visits apply to new patients or to patient visits that take a longer time.

The remaining five sections of Category I codes are:

1. Anesthesia Services (01000 – 01999)
2. Surgery (10021 – 69990)
3. Radiology Services (70010 – 79999)
4. Pathology and Laboratory Services (80047 – 89398)
5. Medical Services and Procedures (90281 – 99607)

The Medical Services and Procedures section overlaps numerically with Evaluation and Management Services, but refers to specific services such as vaccinations, dialysis, and ophthalmology services.

Category II codes are supplemental tracking codes (also known as performance measurement codes). Category II codes are not linked to fees or billing. Physicians use Category II codes to track information about patients. The codes consist of four digits and the letter F. They cover topics that include patient history, physical examination results, test results, and patient outcomes.

Category III codes are temporary tracking codes that apply to new and emerging technologies. The FDA uses Category III codes to collect data that might help it assess new technologies. Category III codes also describe new procedures that may justify a new Category I code if use of the procedure becomes widespread. Category III codes consist of four digits and the letter T. They do not affect patient billings.

CPT Code Modifiers

Modifiers are two-digit codes (two numbers, two letters, or one of each) that are added to other CPT codes to provide additional information. Modifiers provide additional information about the service or procedure described in a CPT code. For example, a modifier might describe the location on the body where a procedure was performed. Other modifiers (sometimes known as pricing modifiers) affect the accuracy of billings.

The failure to use modifiers can result in excessive billings. For example, in some cases a physician will perform more than one surgical procedure at the same time. The billing coder should select a CPT code that describes the performance of those procedures together.

In some cases, a physician might think that the procedures took an unusually long time and will instruct the coder to bill each procedure as if they were performed at different times. The coder should instead add an appropriate modifier that indicates the procedure took more time than the CPT code anticipates. The process of billing separate procedures (known as “ unbundling ”) rather than using the correct CPT code plus a modifier will generally result in excessive billing.

Medical Billing Experts and CPT Codes

Decoding CPT codes does not require a medical degree, but it does require an understanding of medical terminology and familiarity with the intricacies of the CPT coding system. Medical billing experts help lawyers and patients understand whether medical billings are accurate or inflated by comparing CPT codes to medical records.

Medical records often fail to support the CPT codes that coder selected. When the coder uses a code for a more expensive procedure than the patient received or unbundles procedures that were performed at the same time, medical bills are inflated. While medical billing experts use various techniques to help lawyers and patients understand whether medical bills are reasonable, that process usually begins by determining whether the CPT codes on the billing match the services and procedures that were actually provided.

Medical Billing Review in PIP Cases

Mon, 08 Nov 2021 07:30:00 GMT

Florida law requires all private vehicle owners to carry Personal Injury Protection (PIP) insurance. Also known as “no-fault” insurance, Florida’s PIP insurance covers occupants of the insured vehicle regardless of which driver caused the accident.

If an occupant of the insured vehicle receives medical care soon after a car accident that injures the occupant, the company that insured the vehicle must pay 80% of the “reasonable expenses for medically necessary medical, surgical, X-ray, dental, and rehabilitative services, including prosthetic devices and medically necessary ambulance, hospital, and nursing services” that the injury victim receives at any time because of the accident. However, the insurance company is only liable for $10,000 in medical expenses unless the owner purchases a higher coverage limit.

Two key questions determine the injury victim’s right to have medical expenses paid by PIP insurance. The first is whether the victim’s injuries were caused by an accident while the victim was occupying the insured vehicle. The second is whether the medical bills for treatment of those injuries were reasonable and necessary.

Treating physicians typically testify that the treatment they provided was necessary. Florida courts have determined that medical billing experts are in the best position to testify about the reasonableness of medical expenses in a PIP case.

Med-Union Lawsuit

Med-Union Medical Center sued Progressive Express Insurance Company for failing to pay medical expenses from PIP coverage that the insured injury victims assigned to Med-Union. Progressive wanted to call a medical billing expert to prove that Med-Union’s bill was unreasonable.

The trial judge examined a Florida statute that requires an injury victim to submit to a medical examination at the insurer’s request when the victim makes a PIP claim. The statute provides that an “insurer may not withdraw payment of a treating physician without the consent of the injured person covered by the personal injury protection, unless the insurer first obtains a valid report by a Florida physician licensed under the same chapter as the treating physician whose treatment authorization is sought to be withdrawn, stating that treatment was not reasonable, related, or necessary.”

The judge read the statute to mean that only a licensed Florida physician could determine whether medical expenses were reasonable. The judge misunderstood the statute. The quoted section requires a medical opinion to establish that a physician’s medical treatment was not reasonable. The statute says nothing about proving that the charge for treatment was or was not reasonable.

On appeal, the trial judge was reversed. The appellate court concluded that medical billing experts are not required to practice medicine to form an opinion about the reasonableness of billed medical expenses.

The appellate court did agree with the trial judge that if an insurance company wants to “reduce, deny, or withdraw” PIP benefits, it must produce a report that justifies its position. While the statute doesn’t make clear that the report requirement applies to medical billing experts, the services that billing experts routinely provide to counsel include the preparation of a detailed report.

Beyond PIP

Florida’s no-fault approach to insurance has not been adopted by most other states. A recent bill to abolish PIP in Florida was vetoed by the governor. Although PIP in Florida limits the ability to recover medical expenses in many cases, the law does not preclude the opportunity to sue a negligent driver under all circumstances.

Injury victims who suffer permanent injuries in Florida because of another driver’s negligence are entitled to sue the driver who was at fault. Those injury victims can recover all their reasonable bills, as opposed to the 80% and the policy limits that apply to PIP claims. They can also recover lost wages, damages for lost earning capacity, the expense of coping with a disability, and compensation for pain and suffering.

When larger medical expenses are at stake, medical billing experts become the key to proving that medical expenses are or are not reasonable. Florida courts have recognized that medical billing experts can give admissible testimony when the reasonableness of medical charges are disputed.

In a leading Florida case, the appellate court reviewed a trial judge’s decision to exclude a medical billing expert. An insurance company retained the expert to examine the plaintiff’s medical records and billing records. The expert determined that significant charges for services rendered were not supported by any medical record demonstrating that the services were actually provided.

The court determined that billing experts have expertise that ordinary jurors lack. Billings refer to medical services by Current Procedural Terminology (CPT) codes. Billings refer to the physician’s diagnosis by International Classification of Diseases (ICD) codes. A thorough understanding of CPT and ICD codes is necessary to interpret medical billings.

The court of appeals held that the expert had “specialized knowledge and training to express an opinion on whether the medical bills were properly coded and whether they correspond to the medical records documenting the purported treatment.” The expert’s conclusions about the relationship between billings and services provided was relevant to the insurance company’s defense. The opinions were admissible because they were founded on reliable expert knowledge that ordinary jurors lack.

Reasonable Charge Testimony

Medical billing experts also look for errors in billings. For example, when multiple procedures are performed at the same time, it typically takes less time to perform them than it takes when the services are provided at separate times. Billing codes are designed to reflect that time savings. When doctors “unbundle” charges to bill each procedure separately, they are overcharging.

In addition to testifying about billing errors and mismatches between services provided and services billed, medical billing experts can determine whether charges for services rendered are reasonable as compared to the fees charged by other doctors. Courts recognize that usual, customary, and reasonable (UCR) charges may be recovered as damages, while excessive charges may not be recovered.

Medical billing experts use reliable databases to determine the UCR rate for services in the geographic area where the services were rendered. The UCR rate is based on actual charges for the same services by other providers. When a physician’s billing rate approximates the usual charge, it is the customary charge and is therefore reasonable. When the billing rate for a service substantially exceeds the customary rate, it is probably unreasonable. Medical billing experts have the ability to quantify reasonableness by using reliable methodologies to explain why billings are or are not reasonable.

Medical Billing Experts in Uninsured Motorist Litigation

Mon, 01 Nov 2021 06:42:00 GMT

Uninsured motorist (UM) claims are governed by contract law, but damages are generally determined by tort law. The contract requires the insurance company to pay the insured injury victim the compensation that the victim would have recovered from the negligent driver if that driver had been insured (subject to the policy limites).

While Florida requires drivers to have personal injury protection (PIP) insurance, that form of no-fault coverage does not cover pain and suffering. When a negligent driver injures the occupant of a vehicle who is covered by PIP insurance, the injury victim will usually be entitled to sue the negligent driver if the victim suffered substantial and permanent injuries.

The right to sue a negligent driver, however, has little value if the negligent driver is uninsured. Most drivers who can’t afford to buy insurance have no significant assets and a minimal income. More than 20% of drivers in Florida have no insurance. Prudent drivers therefore protect themselves by purchasing UM coverage when they buy their PIP insurance.

Recovery of Medical Bills in a UM Claim

Like tort claims, the plaintiff who makes a UM claim will seek recovery of past and future medical expenses, as well as the loss of wages and earning capacity, the expense of coping with a disability, and pain and suffering.

Florida courts have held that the recovery of medical expenses in a UM claim follows the same standard of proof that applies in a personal injury claim. The plaintiff must prove not only that the expenses were incurred, but that the medical treatment was a necessary response to injuries caused in the accident. Treating physicians usually supply that proof.

In addition, plaintiffs must prove that the medical expenses incurred were reasonable. Medical expenses are reasonable when they reflect the usual and customary charge for the same services by care providers in the same area.

Care providers know what they charge, but they don’t usually have a firm basis for testifying about the charges of other providers. Lawyers for plaintiffs may therefore turn to medical billing experts to prove the reasonableness of charges.

Insurance companies are allowed to contest the reasonableness of charges. They may save thousands of dollars by doing so. Some judges allow doctors to testify that their charges are reasonable even when the plaintiff cannot lay a foundation for that opinion. Insurance company lawyers turn to medical billing experts to refute that testimony when billings are excessive.

Medical Billing Expert Testimony in a Florida UM Case

A Florida case illustrates the value of medical billing experts in UM cases. A driver was injured in an accident with an uninsured motorist. The driver sued State Farm for compensation pursuant to the UM coverage of his auto policy. At trial, the driver testified that his medical bills were reasonable. A jury found in the driver’s favor and awarded him more than $900,000. The trial judge then reduced the award to $100,000, the limits of the driver’s UM coverage.

State Farm wanted to present the testimony of a medical billing expert. The expert testified in her deposition that she had been retained to offer opinions “concerning the reasonableness of charges for medical treatment rendered to” the driver. She testified that she compared the bills to the medical treatment records and found “extreme abuse” in the coding and billing compared to the medical record documentation of four of the driver’s main medical care providers.

The expert testified that as to those four providers, “there is absolutely nothing within that documentation that is supportive or representative of any of the billed procedures that I have reviewed.” Her report also indicated that she reviewed $278,000 in medical bills and found that $111,000 in charges did not have any supporting medical codes.

Prior to trial, the judge granted a motion to exclude the medical billing expert’s testimony. The judge decided that the expert’s opinion would not help the jury decide whether the bills were reasonable. The court apparently based that ruling on the expert’s failure to use the word “reasonable” in her deposition testimony.

Of course, witnesses only answer the questions they are asked. If she was not asked whether the bills were reasonable, she can hardly be faulted for failing to answer a question she wasn’t asked. In any event, expert testimony can be helpful even if the expert does not address the ultimate issue that the jury must decide. State Farm, therefore, appealed after the court entered judgment in the driver’s favor based on the jury’s verdict.

Appellate Decision

The Florida District Court of Appeals concluded that the trial judge erred by excluding the testimony of State Farm’s medical billing expert. State Farm defended the case on the theory that the medical providers fabricated or exaggerated the medical care necessary for the driver’s alleged injuries. The appellate court recognized that the billing expert’s testimony that the bills did not correlate to the treatment in the medical records was relevant to prove State Farm’s defense.

The court of appeals noted that the expert’s proffered testimony related to a technical issue that was beyond the jury’s basic knowledge. The court noted that an understanding of billing codes is beyond the experience of ordinary jurors. The jury had no way to assess State Farm’s defense that the driver was overbilled in the absence of expert testimony.

The appellate court determined that the medical billing expert was qualified to testify. Her training and experience gave the specialized knowledge that allowed her to express an opinion on whether the medical bills were properly coded and whether they corresponded to the medical records documenting the purported treatment.

The trial court conflated the need to prove that medical services are necessary with the reasonableness of charges for those services. While medical professionals might need to address the issue of necessity, the issue of reasonableness does not require a witness who has medical expertise. A billing expert helps jurors understand whether procedures that were billed are actually documented in medical records. Whether those procedures were necessary is a different question.

Finally, the appellate court emphasized that parties have a due process right to present witnesses that are necessary to prove their claims and defenses. State Farm had the right to present the testimony of a qualified medical billing expert to support its defense that the driver was billed for medical services he never received. The court, therefore, granted State Farm a new trial so that it could present the testimony of a medical billing expert.

Medical Billing Expert Testimony in Medical Malpractice Cases

Mon, 25 Oct 2021 09:37:00 GMT

Medical errors are a leading cause of death in the United States. Errors caused by negligence can entitle a patient (or a deceased patient’s family) to compensation.

Expert witnesses help patients prove medical negligence. Doctors usually testify as expert witnesses in a medical malpractice case. When a negligent physician has taken steps to hide his or her error, medical billing experts can also offer testimony that is critical to making a successful malpractice claim.

When physicians attempt to conceal malpractice by altering medical records, they create a disconnect between the treatment records and billings. A careful analysis of billings can provide strong evidence that the treatment records were changed. Altered records often provide the proof that cements a malpractice claim.

Medical Malpractice

Medical malpractice is another term for medical negligence. A physician or hospital commits malpractice by failing to adhere to the treatment standard that governs prudent healthcare providers.

For example, when a patient complains of certain symptoms to a family practice physician, the physician must provide at least the same care that would be expected of an average family practice physician. If the standard of care requires the physician to order certain tests in order to diagnose or rule out specific causes associated with the patient’s symptoms, a physician who fails to order those tests is negligent.

Medical negligence is usually proved through the expert testimony of a physician who practices in the same field of medicine as the defendant doctor. When the malpractice claim is based on a family practitioner’s failure to diagnose a health condition because critical tests were never ordered, the patient will usually call a family practitioner as an expert witness to establish that the standard of care requires prudent family practitioners to order those tests.

Concealed Evidence of Negligence

Nobody is perfect. When ethical doctors make a mistake, they inform their patient of their error. When the mistake harms the patient, the doctor’s insurance company should compensate the victim of the doctor’s negligence.

Unfortunately, not all doctors are ethical. Studies have established that many doctors attempt to conceal their mistakes or shift the blame to the patient or other doctors rather than admitting their errors. Doctors may worry about their professional reputations, while hospital administrators may worry about institutional liability if they fail to cover up a doctor’s mistake.

Surveys show that 7% of doctors believe it is acceptable to conceal errors from patients, while another 14% feel it is acceptable to hide the truth under some circumstances. In practice, since human nature is to think of ourselves as honest until we are presented with a choice to be dishonest, the percentage of doctors who are willing to hide their malpractice is probably much higher than the percentage who are willing to admit their dishonest instincts.

Physicians who try to conceal their malpractice often do so by altering medical records. They might change patient histories to make it appear that a patient never told them about an allergy. They might change medication records to make it appear that they prescribed a different medication than a nurse administered to a hospitalized patient. They might indicate that they advised a patient to obtain a test that the doctor never discussed with the patient.

Case Study – Failure to Diagnose

In a New York case, a patient was examined for a complaint of pain in her breast. The patient contended that the physician told her she had a lump in her breast but advised her that 90% of lumps do not lead to a diagnosis of breast cancer. Several months later, the lump had enlarged and had become noticeable to the patient. She returned to the doctor, who recommended a biopsy. The biopsy revealed the presence of breast cancer.

The patient contended that the physician should have advised her to obtain a biopsy during her first examination months earlier. Had the physician done so, the patient could have commenced treatment earlier and would likely have had a more favorable prognosis. The patient contended the doctor’s failure to recommend a biopsy during the first examination was negligent. The patient’s medical expert offered evidence that the standard of care required an immediate biopsy and that the failure to order one shortened the patient’s lifespan.

The doctor responded that the initial breast exam was normal and that no lump was detected. The doctor claimed that the patient’s medical records confirmed that no abnormality was present during the exam.

However, billing records that had been submitted to the woman’s health insurer contained a diagnostic code that, translated into words, means “unspecified lump in breast.” The billing therefore revealed the doctor’s finding of a lump, a finding he tried to conceal by altering the medical records.

Jurors do not know the meaning of diagnostic codes. Medical billing experts can provide vital testimony to help the jury understand that the diagnosis indicated in billing records establishes that the diagnosis was made, even if treatment records were later altered.

Consequences of Altered Medical Records

Discrepancies between billing records and treatment records raise questions about a doctor’s credibility. Tampering with evidence creates a strong impression that the physician is hiding the truth. In a “doctor said – patient said” case, billing records that suggest the doctor’s deception may tilt the jury’s view of the evidence in favor of the patient.

In addition, when doctors change treatment records to cover up their mistakes, most jurisdictions allow the patient to seek punitive damages as part of the malpractice action. The patient may also be entitled to seek sanctions for spoliation of evidence. The most common sanction is a jury instruction that allows the jury to infer from altered evidence that the evidence was unfavorable to the doctor before changes were made.

Comparing medical records to billing records is a vital part of a lawyer’s assessment of a potential medical malpractice case. Experts in medical billing can conduct that assessment, produce a report, and testify in court if they find a mismatch between treatment records and billing records.

Is a Medical Billing Expert’s Opinion Admissible Under Daubert?

Mon, 18 Oct 2021 03:26:00 GMT

The Federal Rules of Evidence govern the admissibility of expert testimony in federal cases. Rule 702 has long required courts to begin their analysis by asking two questions. First: Is the expert basing an opinion on specialized knowledge, derived from training or experience, that ordinary members of the jury will probably lack? If so, the court asks a second question: Will the expert’s opinion help the jury understand a fact or answer a question that is relevant to the case?

When expert testimony meets those threshold tests, the judge next decides whether the witness is qualified to render an expert opinion. Finally, the judge asks whether the evidence satisfies the Daubert standard.

Whether the evidence is admissible under Daubert is a question that divides the parties in nearly every case in which an expert proposes to testify. Fortunately, the consensus among federal courts (and state courts that have adopted the Daubert standard) is that medical billing experts are able to give admissible testimony.

Applying Daubert

Federal judges have different ideas about what Daubert means. The Daubert decision purports to liberalize the admissibility of expert testimony. Before Daubert , federal courts tended to reject expert opinions that were not based on generally accepted scientific principles. The Daubert decision focuses on whether experts use reliable methods to form their opinions, even if those methods are not yet generally accepted.

Despite its stated intent to liberalize the standard for admitting expert testimony, many judges view the decision as restricting testimony that the judge deems unreliable, even if a jury might find it persuasive. Federal precedent has described the judge’s role after Daubert as that of a “gatekeeper,” admitting testimony that is based on reliable methods while excluding testimony that is not.

In a nutshell, Daubert and its progeny require expert opinions to be based on:

1. sufficient facts or data,
2. a reliable methodology, and
3. the reliable application of the methodology to the facts or data.

Judges may consider several factors when they decide whether a methodology is reliable, such as whether other experts recognize the validity of the methodology and whether it has a known error rate. Some of those factors (such as error rates) apply to experts who use scientific experimentation to arrive at opinions.

Daubert and Nonscientific Testimony

After Daubert was decided, courts were divided about its applicability to nonscientific testimony. When expert testimony is not based on physics, chemistry, or some other “hard science,” the factors that determine reliability are less clear. The Supreme Court resolved the issue about six years after it decided Daubert . In a case called Kumho Tire , the Court held that expert opinions must be reliable even if they are not based on science.

The analysis of nonscientific testimony begins with an assessment of whether the witness’ field of expertise is reliable. As Justice Breyer noted in Kumho Tire , an expert in astrology cannot give reliable expert testimony because the expert is not engaged in a reliable field of study. A lawyer who seeks the admission of nonscientific testimony should therefore establish that the expert’s field is recognized as legitimate.

Justice Breyer also noted that the factors identified in Daubert to determine the reliability of scientific testimony are flexible. Not all of them apply to nonscientific testimony. The ultimate question is whether the expert’s testimony demonstrates the degree of “intellectual rigor” that should be expected of someone who works within a specialized field.

The Kumho Tire decision did not create a list of factors that help judges decide whether nonscientific testimony is reliable. Courts that consider the admissibility of nonscientific opinions generally ask whether the expert:

1. based an opinion on specialized knowledge,
2. adopted a reliable method to arrive at an opinion that removes guesswork or speculation from the opinion-formation process,
3. considered sufficient facts that are derived from reliable sources to support the expert’s opinion, and
4. arrived at an objective conclusion that is supported by the facts.

Courts also ask whether the expert’s reasoning or methodology “fits” the facts of the case. That question generally informs the judge’s decision whether the expert opinion is relevant.

Admissibility of Medical Billing Expert Testimony

Medical billing experts analyze medical bills to determine whether the bills are reasonable. In many cases, the question they must answer is whether a billing represents the usual, customary, and reasonable charge for each service rendered. Experts might also form opinions as to whether the bills offer evidence of fraudulent billing.

Courts recognize that medical billing experts are qualified when they have particular training and experience that most people lack. Learning the complexities of the codes used on medical bills to identify each diagnosis or service is part of the specialized training or education that qualifies medical billing experts to provide admissible testimony. Courts agree that medical billing experts do not need medical training to qualify as expert witnesses.

Medical billing experts gather sufficient facts and data that allow them to form opinions. In addition to medical billings, they rely on medical records and on databases that record the actual costs of specific medical services within a zip code. Courts consider those facts to be sufficient to support an expert’s analysis of a medical billing.

Medical billing experts also derive their opinions from reliable methodologies. They perform a line-by-line analysis of medical bills, looking for double charges or mistakes (such as data entry errors) that result in erroneous charges. They compare medical records to medical billings to determine whether the billing reflects the actual services that were provided.

Medical billing experts rely on their expert understanding of billing codes to assure that the billing does not reflect a more expensive service than the service that the patient received. They examine billings for “ unbundling ” errors that occur when doctors use billing codes for separate services that were provided at the same time. Since lay members of a jury are not trained to interpret billing codes, expert knowledge provides the foundation of the expert’s opinion.

Medical Billing Expert Witness Testimony Allowed in Personal Injury Case

Mon, 11 Oct 2021 10:01:00 GMT

A federal court decision demonstrates why defendants are entitled to use medical billing experts to challenge the reasonableness of hospital and chiropractic bills in a personal injury case. The evidence was needed to counter a doctor’s opinion that medical bills were reasonable.

Jessica Perez alleged that she was driving with her children when a tractor-trailer changed lanes and crashed into her vehicle, injuring Perez and her children, She sued the driver and his employer for negligence. The case was removed to a federal district court in Texas.

In her complaint, Perez alleged that she suffered permanent physical injuries, including disfigurement, as well as continuing mental anguish. Her request for damages included past and future medical expenses, past and future pain, suffering, and mental anguish, lost wages and diminished earning capacity, loss of household services, and the cost of future medical monitoring.

Perez designated a treating neurosurgeon as a non-retained expert. Her summary of the neurosurgeon’s testimony included his “medical diagnosis, prognosis and the reasonable and necessary cost of hospital, doctor and medical bills for treatment of [Perez’s] injuries in the past and in the future.”

Treating Physician’s Testimony About Medical Bills

In his deposition, the neurosurgeon testified that the medical treatment he provided to Perez was necessary and that various charges were reasonable, including the hospital and surgical bill, a chiropractic bill, and a bill for post-surgery treatment provided by a medical center.

The defense made a strong showing that the neurosurgeon could not provide admissible testimony about the reasonableness of the medical bills. The neurosurgeon admitted that he did not review the bills line-by-line but based his reasonableness opinion on “the totality of the charges” and not their itemization. Many courts would regard the failure to scrutinize the bills as an unreasonable expert methodology.

The neurosurgeon also testified that he did not review the chiropractic or medical center treatment records and simply assumed that the care provided in the medical center was related to the accident. Many courts would reject the neurosurgeon’s opinion as to the reasonableness of charges when he made no effort to determine the nature of the care that was rendered.

The court accepted the neurosurgeon’s testimony that “in his role as a treating physician he regularly reviews and is familiar with charges for other treatment,” including chiropractic and medical center care. The court decided that a jury should determine whether the neurosurgeon’s testimony about reasonableness was credible. Other courts in similar situations have barred a physician’s testimony about the reasonableness of charges that are not based on specific data about usual, customary, and reasonable charges for specific services in the community where the services were provided.

Defendant’s Medical Billing Expert Witness

Faced with a court decision that allowed a treating physician to testify about the reasonableness of medical expenses, the defense turned to a medical billing expert to provide competing testimony. Perez filed a Daubert motion to exclude that testimony.

The medical billing expert explained that she reviewed medical and billing records from five of Perez’s medical providers. She compared the medical providers’ billing and coding with the medical documentation “to determine if the coding was properly applied” using standard CPT codes.

To determine whether the charges were reasonable within the zip code where services were provided on specific dates, she used a database. The database is one of many similar sources of information about actual charges that appear in billings by healthcare providers during specific timeframes and within specific zip codes.

The database allowed the billing expert to determine the median charge (or 50th

percentile) for the specific CPT code — that is, the median value “for that same service

in the same given area on the same date of service.” The expert also relied upon the

Texas Price Point website for inpatient usual and customary charges in 2017, using the median charge for hospitals in the county where the medical services were provided.

Perez moved to strike the medical billing expert as a witness on three grounds: her alleged lack of qualifications, the absence of foundation for her opinions, and the lack of relevance. The court rejected each of those arguments and admitted the billing expert’s testimony.

Expert’s Qualifications

The court determined that the defense expert was qualified to give expert testimony. Her extensive training and experience evaluating medical charges satisfied the federal standard. In the words of Rule 702 of the Federal Rules of Evidence, the expert’s “skill, experience, training, or education” gave her “technical or other specialized knowledge” that would help the jury “understand the evidence” and “determine a fact in issue” — the reasonableness of Perez’s medical bills. Her training gave her knowledge of medical coding and medical billing audits that would help lay jurors, who typically lack that knowledge, return an informed verdict.

The court rejected the argument that the expert was not truly an expert because she was not a doctor. Her expertise was in medical bill coding and auditing, not in medicine. She did not need a degree in medicine to be a medical billing expert.

The court also rejected the argument that the medical billing expert had no specialized knowledge because she gathered her information from databases. Experts typically rely on data that they gather from reliable sources. To understand and select data from the database, a medical billing expert must be “proficient in the use of CPT codes , the use of CPT modifiers, billing interpretation, and the different medical fee schedules.” A medical billing expert’s methodology requires expertise that goes beyond procuring data from databases.

Reliability of Defendant’s Medical Billing Expert Opinions

The court rejected the contention that the expert did not establish her reliance on relevant data because she did not personally develop that database from which she extracted data. Experts routinely rely on databases to form opinions. Other experts in the field of medical billing analysis regard databases as reliable sources of information.

The court also disagreed with the argument that the medical billing expert did not use a reliable methodology. The expert explained that her methodology “requires her to evaluate Plaintiff’s medical billing records and compare them to nationwide CPT codes,

apply her expertise to determine whether medical documentation supports those

charges, and evaluate the manner of billing by those providers.” Because the billing expert based her opinions on a reliable methodology, her testimony was admissible.

Medical Billing Expert Testimony Required

Mon, 04 Oct 2021 08:37:00 GMT

In Schemelzer v. Muncy , a federal district court explained why expert testimony about the reasonableness of medical bills is not only admissible but necessary. The court rejected the plaintiff’s attempt to use the testimony of non-experts to prove that their medical bills were reasonable. In light of its ruling, the court allowed the plaintiffs to retain a medical billing expert and to add that expert to its expert witness disclosure.

Facts of the Case

Steven Schemelzer collided with a tractor-trailer driven by Mark Muncy. Schemelzer alleged that Muncy was negligent when he tried to back his rig into a private driveway. Not realizing that the road was obstructed, Schemelzer crashed into Muncy’s truck.

Schemelzer suffered severe injuries, including traumatic brain injuries and bone fractures in his face. Schemelzer’s lawsuit sought recovery of his medical expenses as well as other categories of damages.

Schemelzer understood that, under Illinois law, he needed to prove that his medical expenses were reasonable. He planned to supply that proof with the testimony of a billing employee at the hospital where he was treated. Muncy objected, arguing that only an expert witness can testify about the reasonableness of medical bills.

Proof of Reasonableness

Like other jurisdictions, Illinois permits a plaintiff to recover only those medical bills that are reasonable. Illinois places the burden on the plaintiff to prove the reasonableness of the bills that the plaintiff seeks to recover.

Illinois is among the states that treat the payment of a medical bill as prima facie evidence that the bill is reasonable. That rule is premised on the assumption that people generally do not pay unreasonable bills. If someone (usually the plaintiff’s insurance company) paid the bill, that payment stands as evidence that the bill was reasonable.

Evidence of payment may therefore be sufficient to establish that paid bills are reasonable if reasonableness is not contested. A defendant is nevertheless free to present the testimony of a medical billing expert to establish that the paid bills were not reasonable.

In jurisdictions that regard payment of medical bills as prima facie evidence of reasonableness, a plaintiff might not need a medical billing expert, but only if: (1) the plaintiff does not want to recover damages for medical bills that have not been paid, and (2) the defense does not contest reasonableness by calling a medical billing expert of its own.

As a practical matter, medical bills are usually paid by insurance and insurance companies rarely pay the full bill. A plaintiff who can afford to do so might pay the co-pay or deductible required by the policy, but the insurance company will pay “adjusted” charges, regardless of the amount of the bill.

Plaintiffs who decide to recover only the amount of a medical bill that has been paid are typically leaving money on the table. Hiring a medical billing expert to prove the reasonableness of a larger charge than the charge paid by insurance is a smart investment when the difference between a paid bill and a full reasonable bill is substantial.

Only an Expert Witness Can Testify About Reasonableness

Schemelzer intended to have billing personnel from the hospitals where he was treated testify that the charges billed by the hospitals were reasonable. He expected the billing clerks to say that the charges are the customary and usual charges for similar services in the area.

Muncy objected that the billing clerks were not identified as experts. In federal court, Rule 26 of the Federal Rules of Civil Procedure requires the disclosure of expert witnesses.

Schemelzer responded that the billing clerks were not being asked to testify as expert witnesses. He argued that they were fact witnesses and thus were not subject to expert witness disclosure requirements.

The billing clerks would have testified that their job required them to calculate the hospital bills and to determine what the customary charges were for similar services at other facilities. Because their proffered testimony was based on facts gathered as part of their work, Schmemelzer argued that their testimony about usual and customary charges was testimony about facts rather than opinions.

The district court agreed that the amount of the billed charges is a fact. The billing clerk could therefore testify as fact witnesses about the amount of the charges that were billed to Schemelzer. She could also testify about the portion of the bill that was paid and the amount that remains unpaid.

Whether the unpaid charges were reasonable, on the other hand, was a matter that required expert opinion. If the determination of a fact requires specialized knowledge, only a witness who has such knowledge can provide testimony that will guide the jury’s decision.

The court noted that “the average layperson does not have knowledge of the rates charged for medical services in a particular area.” Since the fact of reasonableness can only be determined by a person who has specialized knowledge, testimony about reasonableness must come in the form of an expert opinion.

The court did not allow the billing clerks to testify about reasonableness because they were not designated as expert witnesses. Fortunately for Schemelzer, the court extended his deadline for identifying an expert witness to establish the reasonableness of the unpaid medical bills.

The Advantage of Using Medical Billing Experts to Prove Reasonableness

A billing clerk might claim that she has specialized knowledge about medical costs in her community, but Rule 702 of the Federal Rules of Evidence demands more. An expert witness cannot simply assert that “this is my opinion.” The expert must prove that the opinion was based on sufficient facts and a reliable methodology.

Cross-examination of a billing clerk is likely to expose the absence of any methodology that supports the clerk’s opinion. If the clerk cannot identify a reliable methodology, it is unlikely that the opinion will be admitted into evidence.

Medical billing experts have developed reliable methodologies that support admissible opinions. Medical billing experts gather facts about actual charges billed by all healthcare practitioners for particular services in a specified geographic area. Billing experts use established databases to compare a client’s billing to the charges that are typical within the community for the same services.

Billing experts identify a range of reasonableness using standards that are generally accepted within their field. Their opinion as to the reasonableness of a particular bill is based on whether the billing falls within that range. By basing opinions on sufficient facts and a reliable methodology, billing experts are able to provide admissible evidence of reasonableness that billing clerks and other lay witnesses cannot give.

Upcoding and Unbundling Charges in Medical Billing Review

Mon, 27 Sep 2021 00:00:00 GMT

Inflated medical billing, whether deliberate or the result of honest error, imposes a financial burden on consumers, insurers, and personal injury defendants. Those errors are often hidden in the complex codes that are used to identify procedures and services for which patients are billed.

A medical billing review can uncover excessive charges. Insurers that challenge a plaintiff’s request for damages, whistleblowers who need evidence to support a claim of fraudulent billing, and anyone who has been victimized by excessive medical bills can benefit from a medical billing review.

Medical Billing Coding

Medical billings are based on codes that are bewildering to patients. Most doctors have only a limited grasp of the coding systems. Doctors and hospitals rely on billing staff to get the codes right.

Medical billings generally include codes that identify a patient’s diagnosis and each of the medical procedures that were performed. Separate sets of codes are used to describe the diagnosis and procedures.

Diagnosis codes were standardized in the International Statistical Classification of Diseases and Related Health Problems (ICD). The tenth revision, ICD-10, will transition to ICD-11 in 2022. Diagnostic codes are used by medical billing departments to support their choice of procedural codes.

The ICD-10 includes tens of thousands of codes that identify a patient’s health condition or injury, the location of the symptom or injury, whether the condition is new or an aggravation of a preexisting condition, and the severity and cause of the condition.

The two most common procedural coding systems in use today are the Current Procedural Terminology (CPT) codes and the Healthcare Common Procedure Coding System (HCPCS). While diagnostic codes explain the results of and reasons for a medical examination, procedural codes explain the treatment that was provided in response to the diagnosis.

The American Medical Association (AMA) maintains and annually revises CPT codes. Since doctors can perform thousands of different kinds of procedures, there are thousands of 5-digit CPT codes. The code for a checkup, for example, is 99214.

Extensive training and experience are required to select the correct CPT code. Similar procedures may require different codes, depending on the exact nature of the injury or condition that is being treated and the complexity of the procedure. For example, the CPT code for surgery to raise or “elevate” a depressed bone in a simple skull fracture is different from the code used to describe surgery that elevates a compound skull fracture.

The codes used by HCPCS were developed by the Centers for Medicare and Medicaid. Billings to Medicare and Medicaid must use the HCPCS. Some private insurers also require HCPCS billing codes.

Most codes (known as Level I codes) used by HCPCS are identical to CPT codes. The codes differ at Level II, which addresses products and medical equipment (such as ambulance rides and medications) for which patients are billed. Level II codes are much more specific in the HCPCS coding system than the CPT system requires.

Upcoding

Given the complexity of coding systems, it isn’t surprising that errors are frequently made when billing departments code medical bills. Many of those errors are inadvertent, but they can be costly to patients and insurers. Some coding errors reflect a deliberate attempt to overbill and thus to defraud patients, insurance companies, or Medicare/Medicaid.

Upcoding occurs when billers assign ICD codes for more severe conditions than the condition that the physician actually diagnosed and CPT codes for more complex and expensive procedures than those that were actually performed. Using the example discussed above, using the CPT code that applies to elevation of a compound skull fracture when the surgeon actually elevated a simple skull fracture would constitute upcoding.

Upcoding results in a higher payment than the doctor earned. A doctor who performs a simple checkup but charges for an extended examination will receive a larger fee. A doctor who upcodes consistently is probably defrauding insurers or the government. Even when the mistake is inadvertent, however, the entity that pays the bill — and the patient who pays a deductible or copay — is harmed.

A Medical billing review is designed to uncover upcoding. Insurance defense lawyers request billing reviews to challenge claims for reimbursement of medical expenses in personal injury actions. A plaintiff’s lawyer may request a billing review to support a whistleblower’s False Claims Act litigation. Any litigation that will be affected by upcoding merits a medical billing review.

Medical billing experts perform medical billing reviews by checking each CPT code against the service that was actually performed as documented in the patient’s medical records. When the CPT code is for a more expensive service than the service that was actually provided, the billing review uncovers evidence of overbilling and possibly of fraudulent billing.

Unbundling Charges

Comprehensive medical procedures should be billed using a CPT code that covers the entire procedure. The coding is intended to recognize that multiple procedures performed at the same time (during a single surgery, for example) take less time to perform than a physician would spend to perform the same procedures at separate times.

Billing a comprehensive code and a code for a procedure that is included in the comprehensive code results in double billing. For example, the code for a cardiovascular stress test assumes that the physician administered an ECG during the test. If the billing includes a code for a cardiovascular stress test and a separate billing for an ECG, the billing is excessive.

Health care providers inflate billings when they assign each procedure a separate CPT code rather than the comprehensive code that should be assigned to multiple procedures performed together. The practice of using multiple CPT codes rather than a single code is known as unbundling. Billings that unbundle procedures, either deliberately or mistakenly, result in higher charges.

A medical billing review searches for instances of unbundling in medical billings. By comparing medical records to medical billings, a medical billing expert can determine whether procedures were performed at the same time. A careful comparison can uncover unbundling errors that result in inflated billing.

Why Do You Need a Medical Billing Expert?

Mon, 20 Sep 2021 07:03:00 GMT

Medical billing experts help lawyers, physicians, and consumers. Here are a few examples of how medical billing experts can assist professionals and patients.

Proving Damages

Personal injury plaintiffs are entitled to recover medical expenses from the parties who caused their injuries. While state laws vary, plaintiffs must usually prove two facts: (1) the bills were incurred for medical services that were a necessary response to the injury, and (2) the bills are reasonable. Treating physicians can establish the necessity of the treatment, but courts have often shut down attempts to have physicians testify that their own bills are reasonable.

Ordinary jurors do not have the knowledge or experience to determine whether a medical bill is reasonable. Most courts require expert testimony to prove the reasonableness of a medical bill. While some states presume the reasonableness of medical bills that have been paid, full payment of medical bills by insurance is rare. If defendants will not admit or stipulate to the reasonableness of medical bills, the plaintiff will need to prove that fact with expert testimony.

Courts have become increasingly reluctant to allow a treating physician to testify that billings were reasonable. While a physician might believe that his or her own fees are reasonable, those opinions are not usually grounded in the reliable methodology required by the Daubert standard. When they are cross-examined, physicians usually admit that they have not systematically examined the fees charged by other physicians for similar services in their communities.

Medical billing experts use reliable methodologies to determine whether medical billings are reasonable. Using databases and other information that they collect, medical billing experts compare billings to prices that other physicians in the same community charge for the same services. Medical billing experts help lawyers overcome Daubert challenges by writing detailed reports, demonstrating that they base opinions on reliable data, and explaining how the methodology they use has been accepted by other medical billing experts across the country.

Defending Against Claims for Damages

Defendants in personal injury cases — and the insurance companies that provide a defense and pay damages — resist paying medical bills that are unreasonably large. Even when the law in a particular state presumes the reasonableness of paid medical bills, defendants are entitled to challenge that presumption.

Medical billing experts examine billings line by line to determine whether charges are inflated. Medical billing has become so complex that errors are common. Medical billing experts catch mistakes, including double billing for the same service. By comparing medical records to medical billings, billing experts determine whether a clinic or hospital has billed for services that were never provided.

Medical billing relies on standardized codes, including Current Procedural Terminology (CPT) codes. Charges for a service depend upon the code that that was assigned to that service. An incorrect code can result in a larger charge than the provider should have billed. Medical billing experts review every code to determine whether they match the service that was provided.

Physicians commonly “unbundle” services that were provided at the same time by coding them as separate services. Billing for separate services implies that each service was provided separately and that the physician devoted the usual amount of time to the performance of each separate service. When two services are provided at the same time, only one code should be used in the billing, perhaps with a code modifier to reflect any increase in time caused by performing two distinct procedures at the same time.

By identifying coding errors, medical billing experts can help insurance defense lawyers challenge the reasonableness of medical billings. When billings are reduced to a reasonable size, juries and opposing counsel may also deem it appropriate to return a smaller verdict or to settle for a more reasonable amount.

Challenging Insurance Claim Denials

Physicians often retain a medical billing expert when insurance companies unjustly deny their billings. Under some circumstances, insurers have an obligation to pay the usual, customary, and reasonable (UCR) charge for services provided to an insured. Insurers sometimes apply their own payment rates without making any effort to determine the UCR rate.

By using databases and other sources of information, medical billing experts can help physicians prove that their billings are within a reasonable range of UCR rates within the community where the services were provided.

Insurance companies also deny claims because they believe a physician used an incorrect CPT code. A medical billing expert can determine whether an error was made and can help the physician correct the problem so that the billing will be approved. If the billing does not reflect an incorrect CPT code, a billing expert can write a report explaining why the correct code appears on the billing.

Detecting Fraud

It’s no secret that some healthcare providers deliberately overbill their patients, insurance companies, or Medicare for services. They do so by charging for services that were not provided, double billing for the same service, imposing separate charges for services that should have been “bundled” and billed as a single service, or using an incorrect CPT code to describe the service that was provided.

On occasion, patients decide to sue their healthcare providers for fraud. When a healthcare provider makes it a practice to overbill multiple patients in the same way, lawyers might even bring a class action lawsuit against the provider. Medical billing experts provide essential evidence in support of those lawsuits.

Medical billing experts also assist whistleblowers who bring claims under the False Claims Act or an equivalent state law. Whistleblowers who report Medicare or Medicaid fraud often work for the doctors who are responsible for the overbilling. Medical billing experts provide objective evidence to corroborate their whistleblowing claims.

False Claims Act cases generally allow a whistleblower to recover a share of the proceeds. A strong report by a medical billing expert can provide the solid evidence that will convince the government to prosecute the claim. When the U.S. Attorney’s office agrees to step into the lawsuit, the government bears the expense of litigation. The whistleblower’s share of the recovery is reduced, but the odds of bringing a successful claim increase. Either way, the whistleblower’s lawyer has a claim for attorney’s fees if the whistleblower prevails. Medical billing experts are a vital part of any lawyer’s strategy for bringing a successful False Claims Act lawsuit.

Medical Billing Review Experts in Personal Injury Cases

Mon, 13 Sep 2021 06:45:00 GMT

Lawyers for plaintiffs and defendants rely on medical billing review experts to prove and defend claims for medical expenses in personal injury cases. Personal injury plaintiffs cannot usually bring a successful claim to recover medical expenses unless they can establish the reasonableness of the plaintiff’s medical bills. A personal injury defendant can often reduce an award of damages by challenging the reasonableness of medical bills. A medical billing review expert can help either the plaintiff or the defendant present an effective case.

How Personal Injury Plaintiffs Use Medical Billing Review Experts

Plaintiffs generally seek the recovery of both special and general damages in personal injury cases. The primary components of special damages are past wage loss, loss of earning capacity, past medical expenses, and future medical expenses.

General damages include pain and suffering. While juries do not follow a formula to compute general damages, studies of trial verdicts have established a relationship between general and special damages. As special damages increase, so do general damages.

It is in a plaintiff’s interest to maximize the recovery of medical expenses. The collateral source rule generally allows plaintiffs to recover those expenses even if they were paid by an insurance company, although the insurer may have a subrogation interest in that recovery. In most jurisdictions, the plaintiff can recover the full amount of billed medical expenses, even if the insurer paid less than the full amount.

As a general rule, a plaintiff may only recover medical bills to the extent that they are reasonable and were incurred for necessary treatment. Necessity is usually proved by the testimony of a treating physician. Reasonableness, on the other hand, often requires proof by a medical billing review expert.

While a physician might be willing to testify that his or her charges are reasonable, a skilled cross-examination will often reveal that the physician has no knowledge of the fees customarily charged for the same services by other physicians in the same community. An uninformed belief that charges are reasonable will be deemed inadmissible in jurisdictions that expect expert opinions to be based on a reasonable methodology and grounded in known facts. Medical billing review experts understand how to formulate opinions about the reasonableness of a billing that satisfy the requirements for admissibility of expert opinions.

In some jurisdictions, medical bills that have been paid are presumed to be reasonable. Other jurisdictions require expert evidence to prove that the bill is reasonable even if an insurer paid it in full or in part. Since insurers rarely pay a full medical bill, a medical billing review expert is usually needed even in jurisdictions that presume the reasonableness of paid medical bills.

How Personal Injury Defendants Use Medical Billing Review Experts

While plaintiffs have an incentive to maximize recoveries, defendants have an incentive to minimize verdicts for damages. An award of medical expenses may be excessive if the award is based on medical billings that are inflated, mistaken, or otherwise unreasonable.

It is a nearly universal rule that juries may only award reasonable medical expenses. While some jurisdictions presume the reasonableness of medical bills that have been paid, those jurisdictions typically permit defendants to challenge that presumption.

Medical bills are unreasonable when billing errors inflate the total charge. Common examples of billing errors include:

Medical bills can also be unreasonable when they exceed the usual, customary, and reasonable (UCR) rate for the billed service. If a bill reflects a higher charge than the same doctor has recently charged other patients for the same procedure, it is not the “usual” charge. If the bill reflects a higher price than is charged by other providers of the same services in the same geographic area, it is not a “customary charge.” A billing that fails either of those two tests is not “reasonable” unless it is justified by a special circumstance.

Medical billing review experts can determine whether there is evidence that a medical bill contains errors or exceeds a UCR rate. Since juries tend to use medical bills as a guide when assessing general damages, reducing an award of medical billings may also result in a lower verdict for pain and suffering.

How Medical Billing Review Experts Analyze Medical Bills

Medical billing review experts perform a line-by-line review of medical billings. They search for duplicate charges and typographical errors that may have resulted in inflated billing.

By comparing medical records to medical billings, medical billing review experts can determine whether charges were assessed for services that were never provided or for drugs and devices that were never dispensed.

Medical billing review experts understand CPT codes and other coding systems that are used in medical billing. Coding is complex. It is easy to make mistakes or to disguise fraud by substituting an incorrect code for a correct code. By comparing services that are documented in medical records to the billing codes that describe those services, medical billing experts are able to determine whether upcoding or unbundling resulted in an excessive bill.

Medical billing review experts rely on databases and their own investigations to determine the usual, customary, and reasonable charges for services in the area where medical services were rendered. Databases provide a wealth of information about customary charges for specific medical services.

A billing for a service that is slightly higher than rates charged by other providers might not be unreasonable. Experts define a charge for a service that is beyond a reasonable range of charges for that service as unreasonable. An objective evaluation of medical billings can assist lawyers for both plaintiffs and defendants in understanding whether a medical billing is reasonable or unreasonable.

How Can Medical Billing Experts Have an Impact on Claims for Pain and Suffering?

Mon, 06 Sep 2021 09:47:00 GMT

In personal injury litigation, medical bills are categorized as special damages. They are specific measurable out-of-pocket losses that result from a defendant’s conduct. Awards of compensation for pain, suffering, and emotional distress are categorized as general damages. They flow naturally from a personal injury but cannot be measured by any objective yardstick.

Plaintiffs need to prove special damages with precision. Typical jury instructions require juries to find that special damages have been established to a reasonable certainty.

General damages, on the other hand, can be inferred from the fact of a physical injury. Juries are entitled to award any amount for general damages, provided that the court regards the award as reasonable.

Given the different nature of special and general damages, it would appear at first blush that the testimony of medical billing experts is relevant only to claims for special damages. When plaintiffs seek to recover medical expenses or when defendants challenge that recovery, medical billing experts often play an important role as trial witnesses.

While medical billing experts cannot offer testimony that will help a jury evaluate pain and suffering, experienced lawyers understand that there is an informal relationship between special damages and general damages. During settlement discussions and at trial, expert opinions regarding medical billings can have an indirect but important impact on the value that lawyers and jurors assign to pain and suffering.

Relationship Between Special Damages and Pain and Suffering

Every case is different. It is possible for a plaintiff to experience extreme long-term pain and suffering even when doctors can do little — and thus charge little — to cure the condition. It is equally possible for a plaintiff to incur substantial medical expenses for an injury that is only mildly troubling.

While each case must be evaluated on its own merits, lawyers generally find that there is a relationship between special and general damages. As a general rule, when special damages are higher, juries award larger verdicts for general damages.

A 2017 study concluded that damages for pain and suffering “highly correlate with the plaintiff’s medical expenses.” The study found that the “strong correlation between economic damages and non-economic damages persists in a large U.S. dataset of judge and jury trials.” In other words, empirical evidence supports the real-world experience of lawyers who believe that juries use special damages as a yardstick that helps them measure awards of general damages.

Multipliers in Personal Injury Settlements

Understanding the relationship between special damages and the value of a pain and suffering claim, lawyers and insurance adjusters often rely on “multipliers” to place a value on pain and suffering. In simple terms, each side will multiply special damages by a certain number — typically ranging from 2 to 5 — to estimate the value of pain and suffering.

Lawyers and insurance adjusters often disagree about the appropriate multiplier to use in a particular case. When an injury is likely to take years to heal, the multiplier might be closer to 5. When an injury heals promptly and causes minimal inconvenience, the multiplier might be closer to 2. Of course, multipliers below 2 or above 5 might also be appropriate when special damages seem unusually large or small, given the nature and extent of the injury.

Multipliers can be a useful settlement tool, but they are not a tool that juries can use. The judge will not instruct the jury to base an award for pain and suffering on a multiplier. Courts in most jurisdictions regard it as improper for lawyers to rely on multipliers in closing arguments.

Still, given the correlation between special damages and jury verdicts for general damages, there is reason to believe that juries rely on multipliers, even if they do not do so consciously. It would not be unusual for a jury to say, “We gave the plaintiff $20,000 for medical expenses and wage loss, let’s award another $60,000 for pain and suffering.” The verdict may reflect a multiplier even if juries don’t expressly use multipliers to calculate damages.

Medical Billing Experts Influence Pain and Suffering Verdicts

In most jurisdictions, juries are not told whether an insurance company has paid certain medical expenses. On the other hand, the jury might not be allowed to hear evidence of the total medical bill unless it is supported by expert testimony that the bill is reasonable.

In most jurisdictions, plaintiffs can only recover reasonable medical expenses. Some jurisdictions permit a presumption that medical bills are reasonable if they have been paid, but the defense is entitled to present expert evidence that the charges are unreasonable. And since medical bills are rarely paid in full, proving the reasonableness of the full bill is necessary to a plaintiff’s full recovery.

Medical billing experts offer opinions that can prove or challenge the reasonableness of medical expenses. That testimony can be critical to both the plaintiff and to the defendant in a personal injury case.

Suppose a plaintiff seeks special damages of $90,000, consisting of a $30,000 wage loss and medical bills of $60,000. If the plaintiff and defense both believe that a multiplier of 3 would reflect the settlement value of the pain and suffering claim, the plaintiff will expect a settlement of $360,000 — special damages of $90,000 plus special damages times 3.

However, suppose insurance paid only $36,000 of the medical bills, leaving $24,000 unpaid. If the plaintiff cannot prove that the full $60,000 bill was reasonable, the case will probably settle for $54,000 in special damages (wage loss and $24,000 in medical expenses) plus 3 times that amount, or a total of $216,000. By not using a medical billing expert to establish that the full $60,000 medical bill is reasonable, the plaintiff will be leaving $144,000 on the table.

Suppose instead that the defendant does not agree that the full $60,000 medical bill is reasonable and asks a medical billing expert to review it. If the billing expert determines that a reasonable charge for the billed services would be $42,000, the defendant would not want to pay more than $288,000 — $72,000 for the wage loss and reasonable medical bills plus three times that amount.

Settlement values and verdicts for pain and suffering are indirectly dependent on the reasonable medical expenses that a plaintiff is likely to recover. Both the plaintiff and the defendant can use a medical billing expert to change the settlement value or the likely verdict for pain and suffering by calculating the reasonable amount of medical expenses.

Why Medical Billing Experts Are Essential Witnesses: A Case Study?

Mon, 30 Aug 2021 10:49:00 GMT

The judge’s decision in a recent federal case illustrates why lawyers need to understand state law regarding the proof required to recover medical expenses. The plaintiffs in a wrongful death case hoped to obtain partial summary judgment in their favor for an award of past medical expenses. Because they did not support their motion with evidence from a medical billing expert , the judge ruled against them.

Facts of the Case

Charles Wyman was a route manager for a company that operates family amusement centers. As part of his job, he serviced arcade machines. Wyman was working on a “claw” arcade game in Las Vegas when he was electrocuted. The electrocution was caused by the reversal of a black wire carrying power and a green grounding wire inside the machine. Wyman had no reason to believe that the wires had been reversed when he opened the machine.

Wyman remained in contact with the electrified machine for about ten minutes before employees of the Fire Department arrived and unplugged the machine. Paramedics then transported Wyman to a hospital. He died before he recovered consciousness.

The machine was manufactured by and purchased from Smart Industries Corporation. Multiple lawsuits were filed, including a wrongful death suit against Smart Industries by the Wyman family, Wyman’s estate, and an insurance company that held a subrogation interest in the claim of Wyman’s employer. The suits were removed to federal court and consolidated.

The suits alleged that the machine left the factory in a defective condition. Smart Industries maintained that its quality control department would have seen that the wires were attached incorrectly, making it likely that the wiring was changed after the game was sold. Wyman’s employer denied making any change to the machine. The court held that a jury should decide whether Smart Industries sold a defective product that caused Wyman’s death.

Summary Judgment Ruling on Medical Expenses

The Wymans’ claim included undisputed ambulance and funeral expenses. The Wymans also sought recovery of a hospital bill of more than $165,000. The Wymans moved for partial summary judgment for those expenses in the event that it proved liability at trial.

Smart Industries opposed the motion, arguing that it needed to complete discovery before it could determine whether there was a basis for challenging the billings. The court granted the summary judgment motion, holding that Smart Industries had not demonstrated that further discovery would help it challenge the medical expenses.

After briefing on the summary judgment motion was completed, Smart Industries took the depositions of Wyman’s treating neurologist and the hospital’s Director of Collections. Those depositions were not taken earlier because the pandemic delayed the completion of discovery.

The neurologist testified that he was “not even aware of the cost of the treatment provided.” The Director of Collections refused to offer an opinion on whether the medical bills were reasonable as compared to other billings for similar services in the community.

Smart Industries moved the court to reconsider its summary judgment decision. It argued that under Nevada law, the Wymans needed to submit proof beyond the authenticated medical bills in order to recover those expenses. It argued that they also needed to submit expert evidence that the bills were “accurate, reasonable, and necessarily incurred.”

The Wymans argued that when authenticated medical bills have been paid, that payment is prima facie evidence that the bills are reasonable. The Wymans argued that the neurologist’s testimony established that services reflected in the billings were necessary.

Court’s Reconsideration of Ruling

The court did not expressly respond to the argument that medical bills are presumed to be reasonable when they have been paid. Some jurisdictions follow that rule and others do not. In Illinois, for example, a long line of cases establish that the payment of medical bills — by the injured party, by an insurance company, or by Medicare or Medicaid — is prima facie evidence that the bills are reasonable, but only to the extent of the payment. Thus, if insurance paid 60% of the bill, the plaintiff must offer evidence that the unpaid 40% was reasonable in order to obtain a verdict for the entire bill.

Nevada law on the reasonableness of medical bills is sparse. Nevada appellate decisions nevertheless appear to require the plaintiff to prove the reasonableness of medical bills, whether they have been paid or not. The district court judge did not do a deep dive into Nevada law, but he rejected the Wymans’ claim that paid bills are presumptively reasonable. He also held that the testimony of the neurologist and the hospital’s Director of Collections fell short of establishing that the medical expenses were reasonable. The court therefore reconsidered its partial summary judgment decision.

If the plaintiffs prove that Smart Industries was liable for Wyman’s electrocution, the judge will require them to prove the reasonableness of medical expenses at trial. Since neither the neurologist nor the hospital representative are in a position to testify that the charges are reasonable, they will need to offer the testimony of a medical billing expert.

Proof of Reasonableness at Trial

Even in states that regard the payment of medical bills as prima facie proof that the bills are reasonable, a medical billing expert may be necessary to prove that unpaid bills are reasonable. In most cases, insurance pays only a percentage of the bill. The percentage paid by insurance is typically less than the usual, customary, and reasonable charge for the services rendered. The testimony of a medical billing expert can establish that the full amount of the bill should be awarded as damages.

In addition, when states regard payment of a medical bill as prima facie evidence of reasonableness, defendants are entitled to challenge the presumption that the charges are reasonable simply because an insurance company paid them. Defendants use medical billing experts to counter claims that medical billings were reasonable.

Expert testimony can be particularly effective when the plaintiffs rely on a doctor to testify that his or her medical charges were reasonable. As the neurologist in the Wyman case candidly admitted, doctors might not even know how much their own practice charges for a particular service. They rarely have personal knowledge of the prices that other physicians in the community charge for comparable services. Effective cross-examination of the doctor, coupled with the testimony of a medical billing expert, can help defendants avoid verdicts for unreasonable medical charges.

Physicians Use Medical Billing Experts to Obtain UCR Rates from Insurance Companies

Mon, 23 Aug 2021 11:57:00 GMT

When patients with managed care plans see an out-of-plan provider, they may be shocked when they are billed for a portion of services that their health insurer refuses to pay. Physicians can be just as surprised when they learn that they must chase the patient for a payment that they expected an insurer to make.

Litigation overpayments from managed care plans often turn on whether the insurer must pay the usual, customary, and reasonable (UCR) rate for services that were provided to the patient. Medical billing experts play a vital role in determining the UCR rate.

What Are Managed Care Plans?

A managed care plan is a form of health insurance that relies on contracts with healthcare providers who agree to work for a reduced cost. The premiums for managed care plans are typically less than the premiums for a policy that allows an insured to received services from any healthcare provider.

Some plans, including health maintenance organizations (HMO), largely require patients to be treated by a primary care physician, although they generally pay for treatment rendered by a specialist if the referral is made by the primary care physician. Other plans, including preferred provider organizations (PPO), allow more freedom to choose physicians outside of the network, albeit at a higher cost. Either plan usually allows patients to obtain emergency care when it is needed without awaiting a referral.

What Are Non-Participating Providers?

Managed care plans make agreements with healthcare providers to pay a pre-determined rate for services. Those providers are “participating providers” because they have agreed to participate in the insurance plan. They might also be known as “preferred providers” or “network providers.”

A common definition of a participating provider is a provider “who agrees in writing to render health care services to or for persons covered by a contract or contracts issued by a health service corporation in return for which the health service corporation agrees to make payment directly to the participating provider.” In simpler terms, a participating provider bills the insurance company rather than the patient and gets paid a rate that is specified in the insurance contract.

A non-participating provider is simply a healthcare provider that does not have a contract with the company that provides health insurance to a patient. They are sometimes known as “non-preferred providers” or as providers who are “outside the plan” or “outside the network.”

How Do Non-Participating Providers Get Paid?

In many cases, non-participating providers can be reimbursed from the patient’s insurance at the rate the insurer has agreed to pay to “out of network” providers. However, since non-participating providers have not agreed to accept that rate as full payment, they may be entitled to bill the patient for the difference between the rate they charge and the rate they are paid. Billing the patient for that difference is known as “balance billing” because the patient is billed for the unpaid balance.

The reimbursement rate to non-participating providers varies from insurer to insurer and from policy to policy. In some cases, reimbursement for out-of-network services may be based on UCR rates. The UCR rate is generally the prevailing rate that is most commonly charged for a particular medical service rendered in a particular geographic area.

When insurers must pay a UCR rate, they often try to pay an artificially low rate. Physicians use medical billing experts to determine whether the actual UCR rate is higher than they payment that the insurer has made.

In some cases, the non-participating physician expects to receive the UCR rate but receives the rate that the insurer has agreed to pay to non-participating providers. The out-of-network benefit is often lower than the UCR rate. It might, for example, be based on the Medicare reimbursement rate. Those situations can result in balance billings to the patient.

What Happens When a Patient Assigns Benefits to a Physician?

While participating providers bill the insurance company directly, some insurance contracts do not permit direct payment to non-participating physicians. Instead, the insurance benefits are paid to the patient, who is expected to use those benefits to pay the physician. This puts physicians in a bind, as patients might treat the insurance benefit as a windfall and refuse to pay the physician.

Because doctors expect to be paid for their services, they typically ask the patient to execute an assignment of benefits before they provide treatment. The assignment relinquishes the patient’s right to receive the payments and authorizes the insurer to pay benefits to the provider rather than the patient.

Unfortunately for physicians, insurance contacts may include an anti-assignment provision. That contract clause prohibits the insured from assigning benefits to providers. Because the patient was not authorized to make an assignment, the insurer refuses to honor it. Courts generally enforce anti-assignment agreements if they expressly state that the patient’s assignment shall be “void” or “invalid” or that any assignment will give no rights to the provider who receives it and will not be recognized by the insurer.

Patients are generally given a subscriber agreement by their health insurer. Like most people who are confronted with legal documents, they don’t read the agreement and don’t realize that it contains an anti-assignment clause. Neither they nor the non-participating physician understands that the assignment of benefits will be unenforceable. Both the doctor and the patient are placed in a difficult position when the insurer refuses to pay the provider directly.

Some states, including New Jersey, have enacted laws that require managed care plans to honor assignments of benefits. Unfortunately, even when assignments are enforced, non-participating physicians do not always receive fair payment for their services.

Litigation Against Insurers to Receive UCR Rates

Some states, including Florida, have statutes that require certain managed care plans to pay out-of-network hospitals for the provision of emergency services to their members. In Florida, the insurer must pay the lesser of the provider’s charges or the “usual and customary provider charges for similar services in the community where the services were provided.”

Providers know the amount that they billed but they may not know whether their billing is consistent with the UCR for the services provided. A medical billing expert can help physicians and hospitals compare their billings to the UCR rate when an insurer refuses to reimburse them for their charges. Medical billing experts can provide evidence in support of litigation to recover unpaid UCR rates.

Medical billing experts have supported other litigation on behalf of physicians. A few years ago, class action lawsuits in New York and California challenged insurance companies that refused to reimburse providers for their services at the UCR rate. Those lawsuits were supported by testimony from medical billing experts. They were settled to the advantage of the physicians.

Tx Court Recognizes Right to Use Medical Billing Experts to Challenge Reasonableness of Medical Expenses

Mon, 16 Aug 2021 11:57:00 GMT

The extent to which defendants were entitled to use medical billing experts to challenge the reasonableness of claimed medical expenses was unclear until a recent decision of the Texas Supreme Court. In a case involving Allstate Indemnity Co., the court made clear that a Texas procedural rule does not supplant the right to call medical billing experts as trial witnesses.

Texas Procedure

In 1979, the Texas legislature passed a law to “streamline” the proof of medical expenses in civil cases. The law has been modified several times since it was first enacted. The current version of that law is found in section 18.001 of the Texas Civil Practice and Remedies Code.

The law allows a party (usually a plaintiff) to file and serve an affidavit stating that specified medical services were provided, that they were necessary, and that the charge for those services was reasonable at the time and in the place where the services were delivered. The affidavit must be signed by the person who provided medical services or by the person in charge of the medical records that show the services provided and the charges made.

If the opposing party (usually a defendant) contests the reasonableness of the charges or the necessity of the services provided, that party must serve a “contravening” affidavit. The contravening affidavit must provide notice of the party’s basis for disagreeing with the facts alleged in the affidavit filed by the plaintiff.

The contravening affidavit “must be made by a person who is qualified, by knowledge, skill, experience, training, education, or other expertise, to testify in contravention of all or part of any of the matters contained in the initial affidavit.” In other words, if the contravening affidavit contests the necessity of the services rendered, it will probably need to be signed by a doctor who practices in the appropriate specialty. If the affidavit contests the reasonableness of the charges for medical services, it will probably need to be signed by a medical billing expert.

When a plaintiff files a timely affidavit and the defendant does not file a contravening affidavit, the plaintiff’s affidavit is sufficient proof that the medical bills were reasonable and that medical services were necessary. Plaintiffs still need to prove the cause of their injuries, but they do not need to introduce expert evidence that the treatment of those injuries was necessary and provided at a reasonable price.

When the defendant files a contravening affidavit that meets the requirements of the statute, the rules change. The plaintiff’s affidavit can no longer use used as evidence of the reasonableness of medical billings or the necessity of services. Instead, the plaintiff must introduce expert testimony of reasonableness and necessity.

Proof of Reasonableness and Necessity

A treating physician can usually testify that services were necessary. Whether a treating physician can testify that charges were reasonable is doubtful.

In most cases, physicians only know the amounts they charge for particular services. They are not often familiar with the usual and customary rates charged for similar services in their community. While a doctor may be willing to testify on direct examination that the billing is consistent with the amounts charged by peers in the community, cross-examination often exposes the doctor’s inability to name other physicians who charge the same rates for the same procedures.

Medical billing experts are in the best position to provide expert testimony that billings are reasonable. By the same token, when a defendant wants to controvert the reasonableness of a billing, the defendant will generally need to rely on a medical billing expert to analyze the billings and testify that they are not reasonable.

Alaniz v. Allstate

Norma Alaniz purchased an auto insurance policy from Allstate that included underinsured motorist coverage. When Allstate did not pay her claim, she sued for breach of contract, among other legal theories. Among other damages, Ms. Alaniz wanted to recover her necessary and reasonable medical expenses.

Pursuant to Texas law, Ms. Alaniz filed affidavits from a hospital and several clinics, an orthopedic surgeon, radiologists, physical therapists, and a pharmacy. The hospital, the orthopedist, and one of the physical therapy facilities collectively billed $37,000, representing the bulk of Ms. Alaniz’s medical expenses.

Allstate served a counter-affidavit from an expert in medical billing and coding. The expert analyzed the Current Procedural Terminology (CPT) codes in the billings to determine whether the providers used the correct codes for billing. She identified a number of billing errors .

Allstate’s expert then used an online database to determine the median charge for the rendered services in the zip code where the services were provided. Based on that methodology, she formed the opinion that some of the charges were excessive. The expert attached a comprehensive report to her affidavit, detailing excessive charges and billing errors.

Requirements for Counter-Affidavits

The trial judge recognized that the expert was highly qualified in medical coding and auditing but determined that she did not meet the qualifications demanded by Texas law. According to the judge, only a healthcare provider who works in the same field of medicine can make a judgment about the reasonableness of medical billing.

The judge also concluded that the expert failed to explain why a charge that exceeded the median was unreasonable. The court therefore struck the counter-affidavit and prohibited the expert from testifying.

The Texas Supreme Court disagreed. It ruled that the expert had years of experience reviewing healthcare bills and that her work experience allowed her to develop an understanding of medical documentation and medical billing practices. The court recognized that doctors often have no understanding of the reasonableness of medical charges. An expert who relies on databases to compare charges at a regional level may be better positioned to express an opinion about the reasonableness of a billing.

The supreme court also rejected the trial judge’s holding that the expert’s conclusions were unreliable because deviation from a median does not prove that a medical billing is excessive. The court concluded that the counter-affidavit did not need to meet a test of reliability. Reliability of expert opinions is a standard for the admissibility of expert opinions, not a standard for rejecting a counter-affidavit.

Defendant’s Entitlement to Rely on Medical Billing Expert

Finally, the supreme court overturned several lower court decisions holding that the failure to file a proper counter-affidavit precludes a defendant from challenging the reasonableness of medical expenses with expert testimony. The statute does not allow the exclusion of testimony. The supreme court chided the lower courts for turning the statute into a “death penalty” on the issue of medical expenses.

The Texas Supreme Court recognized the value of medical billing experts as well as the right of litigants to challenge the reasonableness of medical charges at trial. The bottom line is that a qualified medical billing expert who uses a reasonable methodology will always be allowed to testify in a Texas trial when a plaintiff seeks to recover medical expenses.

Overcoming Hearsay Objections to Medical Billing Expert Testimony

Mon, 09 Aug 2021 10:18:00 GMT

Lawyers who use medical billing experts to question or support the reasonableness of medical billings must anticipate objections to the expert testimony. A common objection, regardless of an expert’s field of expertise, is that the expert is basing an opinion on inadmissible hearsay.

Medical billing experts base opinions on information they acquire from their own experience and on medical billing data that might be compiled by outside sources. A federal court in Illinois explained how lawyers can overcome objections that a medical billing expert is relying on inadmissible hearsay when basing an opinion on data from a commercial database.

Facts of the Case

The customer at a Menards home improvement store was injured in the parking lot when a store employee pushed a train of shopping carts into her hip. The customer sued Menards. The case was heard by a federal district court in Illinois.

As part of her damages, the customer sought compensation for her medical bills. Menards retained a medical billing expert to evaluate the reasonableness of those bills. The expert concluded that the billings did not reflect the usual, customary, and reasonable (UCR) charges for the medical procedures performed.

The customer filed a Daubert motion to exclude the testimony. The customer did not challenge the expert’s qualifications. Rather, the customer argued that the billing expert based her opinion on hearsay and that her opinion was therefore unreliable.

Reliability of Medical Expert’s Opinion

Daubert requires federal judges to act as “gatekeepers,” shielding juries from expert opinions that are not based on adequate facts, reliable methodologies, or the reliable application of those methodologies to the facts. Experts cannot simply express a bottom-line opinion but must explain the opinion. That explanation must identify the facts upon which the opinion is based and must articulate the method by which the expert arrived at the opinion. The expert must also articulate the reasoning that supports the opinion.

The medical billing expert employed a standard methodology to determine whether the services billed to the customer were at or below the UCR billing of similar services by the same provider types within the same geographical area. The expert reviewed the customer’s surgical, orthopedic, and chiropractic bills. She determined that their total cost of $745,327.11 exceeded the UCR cost of $256,739.76 for the services provided.

The facts that supported the expert’s opinion included data the expert drew from a nationwide database of medical billing codes. The database compiles actual charges for medical services that were provided to patients, including the date, the Current Procedural Terminology (“CPT”) code identifying the type of service, the identity of the provider of the medical service, and the zip code in which it was performed.

The expert explained that she used the database, together with her knowledge of CPT codes and billing practices in the medical field, to analyze the reasonableness of the charges associated with the CPT codes submitted for the customer’s medical treatment. If the charges were within the 80th percentile of the cost for similar medical treatment, she classified the charges as reasonable.

Expert’s Reliance on Database

The heart of the plaintiff’s objection went to the expert’s reliance on a database to support her opinion. The customer objected that the database consisted of inadmissible hearsay.

It isn’t uncommon for expert witnesses to base opinions on hearsay. In some cases, the hearsay will be established by other evidence in the case. For example, a physician might be asked to assume that a plaintiff was struck by a shopping cart and experienced no other blow to her hip. The physician will then be asked whether the shopping cart collision caused the hip injury that the physician treated. A hypothetical question that calls for an expert to assume the truth of hearsay is proper if evidence is introduced to prove that the assumed facts are true.

Nobody expected the database to be introduced into evidence, so its hearsay nature could not be overcome by a hypothetical question. The question before the district court was whether the expert was entitled to base an opinion on facts she derived from the database despite having no personal knowledge that those facts were true.

The court answered the question by applying Rule 802 of the Federal Rules of Evidence. The rule provides that if experts in a particular field would reasonably rely on facts or data of a particular kind in forming an opinion on the subject, the facts or data “need not be admissible for the opinion to be admitted.” In other words, an expert can rely on a database if other experts in the field reasonably rely on such databases when they form expert opinions.

The billing expert laid an appropriate foundation for her use of the database. She testified that within the field of medical billing, it is common industry practice to use a CPT code database to compare prices for services. She testified that she reviews a patient’s medical records and billing codes, acquires 80th percentile price data from a database, and compares the two to determine whether the patient’s medical bills are usual, customary, and reasonable. She also testified that she relies on CPT codes because they have been standardized by the American Medical Association.

The court concluded that the standardization of CPT codes in the medical industry made it reasonable to rely upon a database of prices associated with those codes. Since reliance on the database was part of the expert’s reasonable methodology and was consistent with the custom and practice of others in the medical billing field, the database did not itself need to be admissible evidence.

Nor was it necessary for the expert to be familiar with the precise algorithms or formulas used to compile the database. The expert had sufficient knowledge of the database contents to support the court’s decision that basing opinions on data in the database was a reliable methodology. Opposing counsel was entitled to test the expert’s opinions through cross-examination or by presenting its own billing expert.

Objections that a billing expert has based an opinion on hearsay data can be overcome when lawyers anticipate the objection. Having the expert explain his or her methodology, and eliciting testimony that medical billing experts routinely rely on commercial databases to learn about UCR prices, will generally assure that the expert’s opinions are admitted into evidence.

Using Medical Billing Experts to Challenge the Reasonableness of a Plaintiff’s Damages

Mon, 02 Aug 2021 11:30:00 GMT

Both the plaintiff and the defense can benefit from the testimony of a medical billing expert in a personal injury case. Plaintiffs who want to recover medical expenses as part of their damages must often prove that the expenses were reasonable. While reasonableness may be presumed when the expenses were paid, unpaid expenses are open to challenge. A medical billing expert can help the plaintiff establish that the charges (as well as projected future charges) are consistent with the customary, usual, and reasonable charges in the local marketplace for the services that were (or will be) rendered.

Conversely, a defendant may want to use a medical billing expert when the charges appear to be excessive. Courts are generally in agreement that defendants are entitled to call medical billing experts to contest the reasonableness of charges for which the plaintiff seeks compensation.

Reliability of Expert Methodology

Judge Corrigan, presiding in a personal injury case in the Jacksonville Division of the Middle District of Florida, was recently asked to exclude the testimony of a defendant’s medical billing expert. Qualified experts are generally permitted to testify in federal court if they form expert opinions by applying a reliable methodology to sufficient facts in a reliable way.

The defense expert analyzed the medical bills for which the plaintiff was seeking compensation. The billing expert determined that “the medical procedures were not correctly billed, and that the bills far exceed the usual, customary and reasonable charges for the services rendered.”

Judge Corrigan noted that the billing expert had “significant education, training, and experience in the field of medical billing and coding.” The court had no difficulty concluding that the expert was qualified to testify about the reasonableness of the charges and whether medical procedures were correctly coded in billings.

The plaintiff contended that the expert testimony was not based on a reliable methodology. Judge Corrigan determined that the expert-based each opinion on reliable methods.

The expert explained that he examined the bills to search for upcoding or the assignment of a Current Procedural Terminology code for a more expensive service than the service that was actually provided. Comparing services identified and described in medical records to services billed was a reasonable methodology for determining whether the billings were infected with upcoding.

The expert also examined billing records for unbundling of services . “Unbundling” refers to the assignment of billing codes for two separate procedures that were actually performed at the same time, resulting in a higher charge than was warranted by the time it took to perform the procedures. Again, comparing medical records to billings was a reasonable way for a trained coding expert to determine whether unbundling resulted in excessive billings.

To calculate the usual, customary, and reasonable (UCR) charges for the services rendered, the expert relied upon benchmarks from the “resource-based relative value scale,” a physician payment system used and endorsed by the American Medical Association, the U.S. Department of Health and Human Services, and many other medical providers. The plaintiff’s attorney argued that the scale was not applicable to an insured, self-pay plaintiff. The expert testified that the scale applied and the plaintiff offered no evidence to the contrary. The court concluded that the testimony was based on a reasonable methodology and was therefore admissible.

Helpfulness of Expert Testimony

In addition to being reliable, expert testimony must be helpful to the jury. Expert testimony is helpful when it helps a jury decide a disputed issue in the case. If an expert plans to tell jurors something they already know, or offers opinions that aren’t relevant to the case, the expert’s testimony is inadmissible because it isn’t helpful.

The plaintiff argued that the billing expert’s testimony was unhelpful. Judge Corrigan rejected that argument because it was based on precedent that addressed the necessity of treatment rather than the reasonableness of billing.

Like most jurisdictions, a Florida plaintiff who seeks the recovery of medical expenses must prove not just that the expenses were reasonable, but that they were medically necessary. Medical necessity is typically established through the testimony of the treating physician or, in the case of future expenses, a medical expert who believes that specified treatment will probably be necessary for the future.

A billing expert might not be qualified to testify that a particular medical procedure was unnecessary. On the other hand, a billing expert may be well qualified to testify that the charge for a particular medical procedure was unreasonable.

The plaintiff’s argument was based in part on the district court’s decision in Maluff v. Sam’s East . In Maluff , the district court concluded that while a billing expert “may be qualified to opine on whether Plaintiff’s treating physicians double-billed for a certain procedure or incorrectly charged for a certain injury, she cannot speak to Plaintiff’s injuries or the appropriateness of certain treatments.” Defense attorneys need to use a medical expert rather than a billing expert to challenge the necessity for treatment. Nothing in Maluff , however, supported the argument that a billing expert cannot provide helpful testimony about the reasonableness of charges for necessary treatment.

Maluff relied upon the Eleventh Circuit’s opinion in Castellano v. Target Corporation . The court’s one-sentence discussion of medical billing in the Castellano case focused on the “expert’s broad lack of knowledge of the background and underpinning of the information in the DRG on which the expert relied considerably.” The expert apparently failed to demonstrate a sufficient understanding of a patient classification system (diagnosis-related group, or DRG) that standardizes prospective payment to hospitals. The Castellano decision addresses the expert’s qualifications, not the admissibility of testimony regarding the reasonableness of medical billings given by a qualified medical billing expert.

Judge Corrigan considered the Florida court’s decision in State Farm v. Bowling to be a more useful precedent. The defendant in that case proposed to have an expert testify that she compared the plaintiff’s medical bills to the medical treatment records and found “extreme abuse” regarding “the coding, billing, and medical record documentation” of four medical care providers. She testified that with regard to those four providers, “there is absolutely nothing within that documentation that is supportive or representative of any of the billed procedures that I have reviewed.” She identified about $111,000 in improperly documented charges. The appellate court determined that the testimony was helpful and should have been admitted.

Judge Corrigan concluded that the billing expert, like the expert in Bolling , would offer helpful opinions that would assist the jury in deciding whether the plaintiff’s medical billings were reasonable. Judge Corrigan, therefore, allowed the defense to call the medical billing expert as a witness.

Medical Billing Experts Assist Whistleblower Lawsuits

Mon, 26 Jul 2021 08:41:00 GMT

Whistleblowers serve the public when they expose fraudulent healthcare billings to Medicare and other government programs. Laws that enable qui tam lawsuits allow whistleblowers to benefit themselves as well as the public. When they prove that the government was defrauded, prevailing whistleblowers are allowed to keep a percentage of the award against the fraudulent biller. Medical billing and coding specialists often provide a vital part of the whistleblower’s proof.

Qui Tam Lawsuits

Qui tam is the short version of a long Latin phrase that might be translated as “suing on behalf of the king as well as himself.” While America is not ruled by a king, qui tam is used in modern American law to refer to a lawsuit brought on behalf of both a whistleblower and the government.

Most qui tam lawsuits are brought under the federal False Claims Act or equivalent state law. The False Claims Act allows individuals who are not government employees to sue government contractors who commit fraud against the government. For the purpose of the False Claim Act, a contractor is someone outside of the government who bills the government for goods or services.

In recent decades, most suits under the False Claims Act have been filed against doctors, clinics, hospitals, and other healthcare providers who deliberately overcharge for services provided (or not provided) to patients receiving Medicare, Medicaid, or other public health benefits. The suit seeks recovery of payments made because of fraudulent billings.

The False Claims Act rewards the person who brings the suit by allowing that person (known as the relator) to keep a percentage of any award or settlement. The U.S. Department of Justice has the option of taking over the case. If it does so, the relator receives a smaller share of the proceeds. However, statistics suggest that the relator is more likely to prevail when the government intervenes.

Medicare Fraud Whistleblowers

False Claims Act lawsuits are typically brought by whistleblowers. In cases involving fraudulent medical billing, relators are often employees of the healthcare provider who decide to blow the whistle on their employer’s fraudulent billing practices. In some cases, relators are patients who realize the government is being billed for services that they never received.

Whistleblowers who bring a False Claims Act lawsuit must file a complaint under seal in federal court. All parties keep the lawsuit confidential while it is pending.

The relator must provide a copy of the lawsuit to the U.S. Attorney in the district where the lawsuit was filed. The government then decides whether it wants to intervene in the case. In addition to improving the likelihood of a favorable outcome, government intervention assures that government bears the cost of bringing the suit. Most relators are willing to take a smaller share of the ultimate proceeds in exchange for having the power of the federal government on their side.

The Justice Department reports that more than 600 qui tam lawsuits have been filed in each of the past several years. The government recovered at least $2 billion, and often more than $4 billion, from whistleblower lawsuits in each of those years. False Claims Act lawsuits are particularly attractive to attorneys because a fee-shifting statute requires the defendant to pay the fees of the prevailing party.

Disclosure Statements

When the relator gives the government a copy of its complaint, he or she must also provide a detailed disclosure statement. The statement must disclose “substantially all material evidence and information” that the relator has gathered in support of the claim.

To comply with the requirement that a disclosure statement should include “substantially all material evidence,” relators will want to gather as much evidence as possible before filing suit. A brief summary of the facts will not comply with the law and will probably not persuade the government to intervene.

Including expert evidence in a disclosure statement enhances the likelihood that the government will decide to pursue the case. An expert’s review of billings assures the government attorneys that solid evidence supports the whistleblower’s claim.

Evidence Provided by Medical Billing Experts

Whistleblowers and their attorneys often retain the services of a medical billing expert well before a False Claims Act lawsuit is filed alleging fraudulent billing in Medicare or Medicaid cases. A medical billing expert can identify billing discrepancies and help whistleblowers establish the existence of fraudulent billing practices.

Medical billing experts decode the charges in medical bills. Healthcare providers are able to conceal fraud because the codes used in medical bills are indecipherable to people who lack experience with medical billing systems. Several different coding systems may appear on medical billings that date back many years, including Common Procedural Terminology (CPT), Healthcare Common Procedural Coding System (HCPCS), Diagnosis Related Groups (DRG), International Classification of Diseases (ICD), and National Drug Codes (NDC)

A medical billing expert can compare codes to the treatment that was actually rendered. Experts identify services that were miscoded. Incorrect coding often induces the government to pay more than the allowable cost for the service or drug that was provided. By building a database, a medical billing expert can itemize fraudulent billings, making it possible to calculate the government’s losses.

A medical billing expert helps relators win cases by telling a story that jurors understand. The expert’s report reveals fraud by piecing together evidence from a history of billings. Billing experts give realtors and their lawyers the ammunition they need to demonstrate a pattern of irregular billing that rules out the likelihood of an innocent mistakes.

The Benefit of Independent Experts

In some cases, the whistleblower in a qui tam lawsuit was responsible for the defendant’s billings and was fired after objecting to fraudulent practices. Relators sometimes attempt to act as their own expert witness when they have knowledge of fraudulent billings.

While whistleblowers who prepared billings have valuable knowledge of their employer’s fraudulent intent, they also have a vested interest in the outcome of the case. A jury might question the credibility of a whistleblower who has a financial stake in the outcome. An independent expert who can confirm the existence of fraudulent billing practices strengthens the relator’s evidence and enhances the likelihood of a favorable outcome.

Rooting Out Errors and Fraud Based on Upcoding and Unbundling

Mon, 19 Jul 2021 08:24:00 GMT

Have you ever taken a look at the papers that come in the mail shortly after your doctor’s visit, or do you read the words “This is not a bill” and throw it in the—ever-growing—shred pile that you’ll get to later?

You should always take a look at this explanation of benefits that is sent to you by your insurance because it will break down the services and procedures they were told you received at your doctor’s office, what portion of the cost they will cover, and if there is anything that you are expected to still owe after insurance has paid their portion.

You wouldn’t just toss your credit card statement in the shred pile without making sure that you recognize all the charges on it. Why would you do the same thing with your health information?

There are two ways providers can get more from your insurance company than they are really owed. Read below for more information about Upcoding and Unbundling.

What is Upcoding?

Just like when you are upcharged at the mechanic for a premium version of synthetic oil, upcoding is when a code for a more expensive treatment or service is used instead of the correct code which would bill at a lower amount.

One primary example of this is when a code is used to indicate that services were provided by a physician, when in reality they were actually provided by a registered nurse. This causes a discrepancy because services performed by a physician are reimbursed for a higher amount than services that are performed by a nurse.

Evaluation and management codes have different levels depending on what kind of office visit it is to evaluate and manage the condition of the patient. Another example of upcoding is to use a code that is a higher level than that of the provided service or treatment.

In terms of conditions, there are two different forms they can take: acute, meaning the condition developed suddenly and/or only lasts a short time, and chronic, meaning that the condition develops slowly and can last for a significant period of time.

In some cases, a chronic condition may be the proximal cause of an acute condition: such as chronic osteoporosis weakening the bones to the point where a minor impact causes a broken bone, which is an acute condition. This is not the same thing as an acute condition being described as a chronic one.

What is Unbundling?

Sometimes in order to determine or rule out certain illnesses, a number of tests are run at the same time: for example, different tests done from the same blood draw to screen for blood sugar, lipids, etc.

When lab tests are commonly performed together, they are often “bundled” to reflect that it was intended for them to be done at the same time, and so they are reimbursed at a lower rate because they can be performed together as opposed to having to be run separately.

When these kinds of tests are “unbundled” and billed individually instead of together as they should be it means that the payer pays more than they should, regardless of whether it is a private insurer, Medicare or Medicaid.

Another example of unbundling is when anesthesia is unbundled from a cardiac procedure. There are very specific circumstances in which this can be done, and it is when there is a separate procedure performed that would not ordinarily be done on the same day, by the same surgeon.

Is It Fraud or Is It An Error?

There are thousands upon thousands of CPT codes that are used to report services and treatments to health insurance payers to reimburse the providers. Every now and then, there are bound to be errors where someone enters the wrong code, or misinterprets a treatment and puts individual codes instead of combining them together.

However, take a careful look at your explanation of benefits when it arrives in the mail (or when you check it on line) if there is a pattern of seeing amounts billed higher than they have been previously, or if you see items on there that you don’t remember, give your doctor’s office a call and see if they can explain it to you.

Billing for services is a complicated process, and it is not always straightforward to determine what is and is not appropriate billing. Medical billing experts can look over your records and determine where there are inconsistencies and help you if you have doubts.

Furthermore, if a provider is regularly and intentionally upcoding or unbundling to increase the amount they are billing to insurance, this is fraud, and there are severe penalties if they are found practicing fraud, which is all the more reason to enlist medical billing experts if things do not look right to you.

Why You Need Medical Billing Analysts

It is highly recommended to hire medical billing experts to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, one of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

Medical Billing Analysts offers litigation support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represent both defendants and plaintiffs with regard to improper medical billing and coding.

The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses and based on local CPT codes they can also perform a Cost Projection Analysis of future costs. Through meticulous analysis, we can justify reasonable cost of services which assists in resolving the case.

Contact Medical Billing Analysts by phone or email at 800-292-1919 or intake@medicalbillinganalysts.com . We’re here for you, whether you need an evaluation of a single charge, or a complex injury case.

What Goes Into an Expert Witness Report?

Mon, 12 Jul 2021 14:25:00 GMT

What do you do when you have a complex issue that is crucial to your case, but difficult for an average person to understand because it is related to a highly specialized field? You get the help of an expert witness.

The primary function of an expert witness is to explain information to the jury in a way that helps them understand something about the case. This can be anything from technicians explaining the results of forensic testing in a murder, an economist’s analysis of financial records for a fraud case, or medical billing experts discussing the importance of how medical services were charged to recover damages in an injury case.

Depending on where your case is taking place, there are different rules for what is required of an expert witness’s report in order for it to be accepted by the court. Read on below for three important tips about your expert’s report.

What is Required in the Report?

Federal courts have much stricter rules for what is required than most state courts. Generally, they want more information to be submitted, but any attorney preparing a case with an expert witness should understand the rules of their jurisdiction.

For example, your expert may be required to prepare and sign a report that will be disclosed to the opposing counsel and which includes a statement of every point the expert will make during their testimony, all of the data used to prepare such a report, what qualifies the expert to offer their opinion, any other cases they have worked on in a specified period of time.

The expert may also need to disclose what he or she is being provided in terms of compensation and the terms: for example, are they being paid a flat rate for their appearance or an hourly rate for the time it took them to prepare their report, and some means of tracking the time spent.

In-state courts, all that may be required is that the expert’s opinions are disclosed to the court. It may be advantageous for the identity of the expert to be revealed along with a formal report. This increases the chance that the expert that has been chosen will be allowed to testify on the case.

What Should Be in the Report?

The expert’s report may be given to the jury to read, so it should be able to explain the issues about which the expert will be testifying without the need for further explanation.

The whole point is to break down information that requires expert knowledge to the level that an ordinary person can draw the correct conclusions from the report. It should not be overly technical or include a lot of jargon specific to the expert’s field of study.

The expert’s report should not give too much information, as this allows opposing counsel the opportunity to do extensive cross-examination. However, if it is not detailed enough, a jury may be of the opinion that the expert is not credible enough and this could adversely affect the case.

A good approach is to strike a balance between clear and concise language, and using technical terms when they are required, but providing an explanation of what they mean so that the reader can use that information to build a basis of knowledge for reading the rest of the expert’s report.

It is useful for the expert to reference accepted studies, standards, and reputable sources that can be verified in order to lend authenticity to the claims they make within their report.

Why You Should Look at Your Expert’s Report

It is no small feat to work with an expert on preparing a report or testimony for a case. Whether or not they take the stand or their report is simply admitted as an exhibit in the trial, it is important to look over the report before submitting it to the court.

The attorney on the case should always make sure that the opinions the expert is voicing are good points and that all the opinions expressed in the report are in keeping with the facts. Medical billing experts preparing a report on the cost of treatment following an accident have the advantage of working from the numbers provided in terms of what a patient paid, but other fields may be open to more interpretation.

Most of the time, communication between an attorney and the expert preparing a report for the case is protected communication. To fall under Federal protection, this communication must be regarding either the expert’s compensation for their report, facts or information provided to the expert that they used to form their opinion, or assumptions given to the expert that they used to form their opinion.

Why You Need Medical Billing Analysts

It is highly recommended to hire medical billing experts to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regard to the finances involved in your medical care.

The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses, and based on local CPT codes they can also perform a Cost Projection Analysis of future costs. Through meticulous analysis, we can justify the reasonable cost of services that assists in resolving the case.

What is a Future Cost Projection, and When Does Your Client Need One?

Mon, 05 Jul 2021 13:55:00 GMT

We hope it never happens to us. There is a catastrophic accident that leaves someone paralyzed, or even a workplace injury that causes the loss of digits on one or both hands. In either of these cases, accommodations have to be made for the future in order for the injured party to maintain their quality of life.

Whether it is the need to have in-home care to assist the injured person with the activities of everyday life, or the need to make arrangements for someone who has lost a thumb on their dominant hand to go through physical therapy to retrain their other hand to perform everyday tasks, there are costs associated with each.

But what is a fair amount for compensation? If there was a single set amount, it would be easy to determine what would have to be paid to ensure future care, but each situation is different and that is why you should read on for when your client might need a future cost projection.

Why You Need an Expert Report

Whenever you have a circumstance which is not well understood by the average person, then you need to have either an expert report or an expert witness. Because the jury in a trial will consist of average people who do not have comprehensive knowledge of the medical billing field, you will need an expert report.

In the case of a future cost projection, medical billing experts will look over what has been charged to the patient to date and what the reasonable cost of ongoing care will be. This, of course, depends on the region of the country and the nature of the care that the patient receives for their accident or injury, which is all the more reason to have an expert weigh in on the cost projection.

Because these costs are not standardized and do vary across the nation, having someone with a local office is important so they know what numbers they are working with when it comes to anticipating future costs for the person in the case.

Reasonable Certainty

Whenever there is an argument for future medical costs to be included in a settlement, there has to be a reasonably certain expectation that medical costs and care will continue into the future, such as physical therapy, assistance services, dialysis, or any other treatment that is crucial to the patient.

This is why it is important for medical billing experts to review the previous medical bills and expenses in order to determine what the patient is likely to pay moving forward.

Future Cost Projection

A future cost projection is different from a life care plan in a number of key ways, namely that a future cost projection is a much simplified version of what goes into creating a life care plan.

Where a life care plan will involve a medical record review and a consultation with a database to project future care costs like a cost projection, it will go more in depth and consult with several different providers of a service and determine the average cost of treatment in a vendor survey.

If it is applicable to the situation, a life care plan may involve interviewing family members and physicians in addition to the client to get a comprehensive picture of what their care situation will look like.

There are areas where a cost projection is the better way to go. While it may seem like the cost projection is the inferior of the two avenues to take, it is extremely powerful before the litigation as a threat of testimony from an expert along with evidence of the damages caused.

Future cost projections are not ideal for trial testimony, but the majority of tort cases, indeed, upwards of eighty percent of them, are settled without going to trial.

The reason future cost projections are not used more is that they typically require upfront costs in the form of having medical billing experts review the medical bills and other documentation and formulate the report. The previous medical bills may even be admitted into evidence depending on how the case is handled and can be used to form a solid basis for how much the client will need in order to maintain their care going forward.

This is weighed against the possible recoverable amount of money from the case, which is usually determined by insurance policy limits. There is only so much that will be reimbursed from an injury or accident, but they can help speed along the process of obtaining a settlement and in some cases obtain a higher settlement for the injured party.

In order to make the most of the argument that the future cost projections are reasonable and accurate, it is necessary to have medical billing experts who understand the healthcare market, what expenses are likely to be considered and awarded, and have them prepare their report accordingly.

Why You Need Medical Billing Analysts

It is highly recommended to hire medical billing experts to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

Medical Billing Analysts offers litigation support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represents both defendants and plaintiffs with regard to improper medical billing and coding.

A New Law Takes Aim At Surprise Medical Bills

Mon, 28 Jun 2021 11:59:00 GMT

The last thing you want after surviving an accident is to find that you have been charged an exorbitant amount for being taken by helicopter to the nearest hospital, where a doctor performed immediate surgery to save your life.

New legislation passed by Congress seeks to protect patients from unexpected medical expenses. Read on below for more information about the No Surprises Act.

What is the No Surprises Act?

The No Surprises Act was passed in late 2020 as a way to help protect consumers from receiving high medical bills for necessary treatment, just because they have a certain health plan.

The No Surprises Act will apply to all health plan years that start on or after the first of January in 2022. It applies to the vast majority of employer health plans (private healthcare plans) and non-group healthcare policies that are offered within and without the marketplace.

As it stands, providers are currently able to bill a patient for the difference between the rate an out-of-network provider charges and the amount the health plan will reimburse. This is called balance billing and is responsible for millions of dollars billed to patients every year.

Under the No Surprises Act, a health plan cannot hold a patient liable for unexpected expenses from out-of-network providers. These kinds of expenses are usually incurred in emergency situations where patients must receive treatment at the nearest facility, which may not be in their network. In non-emergency situations out of network, costs may be incurred by a specialist like an anesthesiologist from whom the patient did not elect to receive their care.

How Are Patients Protected?

Several aspects of surprise bills are covered under the new law. Private health plans must now cover services at in-network rates, including emergency services like air ambulance and non-emergency out-of-network services.

These must be covered with no prior authorization required and a “recognized amount” will be used as the basis for determining what the cost-sharing should be. This will typically be the median amount that is covered by the healthcare network for the same service or near enough to use it for a cost comparison. Medical billing experts are typically knowledgeable about these median amounts in their area and can help inform decisions in this regard.

Balance billing—described above—is now prohibited under private plans, it was already prohibited under the Medicare and Medicaid public plans.

Out-of-network providers cannot pass excess charges along to the patient. There is language in the law that prevents providers from directly billing patients for the full amount of services and issuing refunds only if patients knew they were protected from surprise billing and sought compensation. The new “shall not bill” language puts the responsibility on the providers to determine appropriate billing with regard to the patient’s insurance status.

Payments and Provisions

Due to a disagreement in Congress as this issue was debated, there is a compromise in how payment amounts for surprise bills will be negotiated: An Independent Dispute Resolution (IDR) process is available for any surprise bill after a period of 30 days where the plan and the provider try to come to an agreement. Each party will submit terms and the IDR decides which is the winner. The decision is final and legally binding, and whoever loses must pay for the cost of the arbitration – this is designed to encourage everyone involved to submit reasonable bids.

Patients can plan ahead for their treatment by acquiring an explanation of benefits in advance, showing what the health plan will pay for and what the patient will ultimately pay for their services.

If a provider leaves the network, health plans must provide continuing coverage at the in-network rate for 90 days after the departure, or until treatment is complete, whichever happens first.

Implementation

As with any resolution, it is not perfect, and the No Surprises Act is open to potential issues with its implementation. These new requirements create significant effort requirements for providers and health plans, and it is uncertain how well IDR entities will handle the capacity of disputes.

In addition, an extraordinary amount of data will have to be collected, collated, and made public. For each bill that resolved by the IDR process, the Secretary of Health and Human Services must post the identity of each party, the location where they are in the country, and the nature of the surprise bill.

The out-of-network payments pose an incentive problem as well for health plans and providers. If the required payments are too high, then providers may leave the networks. If the payments are too low, health plans may not be competitive in the amounts they pay to keep providers in their network. Medical billing experts will have many new standards to consider as early as the first of July in 2021 when the first steps of this law are implemented.

Why You Need Medical Billing Analysts

It is highly recommended to hire medical billing experts to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regard to the finances involved in your medical care.

What Do Medical Billers Mean by UCR?

Mon, 21 Jun 2021 11:19:00 GMT

How does your insurance decide what they will pay for treatment? Why are some procedures covered more than others? Well, it depends on where you live and which doctor you see.

Because many health plans have a large network, they want you to see a doctor in that network because they have already negotiated terms with those providers as to what they will charge for your care and how much the insurance company will reimburse them for, leaving you to pay the difference.

If you see a doctor outside of your network, that is where things get a little tricky. Typically, your insurance company will set a threshold on what they will pay for a procedure based on what the doctor usually charges and what other doctors in the area typically charge.

Read on below for more information on what UCR stands for.

What Does UCR Mean?

UCR is the abbreviation that stands for “Usual, Customary, Reasonable” and they are the three criteria health insurance companies use when they determine the value of medical treatment or service provided. The UCR rate is also used by medical billing specialists to figure out if treatment was billed correctly or not.

U – The “Usual Fee”

This is the usual amount that is charged by a medical practitioner for a device or a service. This is determined by whether they have previously charged other patients a similar rate for the same service, thus establishing regularity in their practice.

C – The “Customary Fee” is the fee for the service compared to the fee typically charged by other medical providers who practice the same type of medicine, and who are in the same region. This allows for the establishment of the “going rate” for a service, and there is usually a range of fees that practitioners will charge for a service in their area.

R – The “Reasonable Fee” charge is considered reasonable if it is BOTH usual and customary, or if it is a medically necessary procedure to save the patient’s life.

When used together, these are abbreviated to “UCR” for brevity and they refer to the charges that a health plan is willing to reimburse after the treatment is provided.

How Do you Know What You Have to Pay?

All insurance companies are different and there is no hard and fast rule for how they calculate a UCR rate. However, many insurance companies will set their UCR rate at a level that covers 80% of practitioners in a given area, or, the 80 th percentile. This means that in that region, 80% of the doctors providing treatment are charging at or below the UCR rate.

If you have treatment provided by a doctor who is over the UCR rate for your insurance company, you will have to pay the difference in your treatment cost which is above what they are willing to reimburse.

Say that you suffer an injury that is neither life-threatening nor a workplace compensation claim: You twist your ankle while playing basketball with some friends and you need surgery to repair your Achilles tendon.

If you get the surgery to fix it through a provider that charges you $7500 for the surgery, but you have an insurance company that has a UCR rate for that surgery of $5000, then you are responsible for paying the difference of $2500, plus any remainder of the $5000 after your insurance pays their portion (typically 70-90% of the procedure cost). This $2500 is called the “UCR fee” because it is the fee you have to pay above the UCR rate set by your insurance because you went to an out-of-network doctor.

If you frequently use out-of-network doctors like this and you have to pay above the UCR rate, that is usually not counted toward the total deductible you pay, or the maximum your insurance will expect you to pay out of pocket for the year, therefore, you will never hit a cap on paying these high medical bills. Fortunately, most HMO and PPO plans have a wide network of providers, so you shouldn’t need a doctor outside your network very often.

This information is used by your health plan and insurance company to decide how much they are willing to reimburse for a medical service in a given geographical area.

What About Prescriptions?

It is very unlikely that you will have to pay a UCR fee for a prescription. The UCR rate for prescription drugs is what someone without insurance would pay, or, the “cash price” so even if it costs you $70 to fill your Cymbalta prescription, you still aren’t paying the full market value that would be charged to someone without insurance, so you will not be exceeding a prescription drug maximum.

Why You Need Medical Billing Analysts

It is highly recommended to hire a medical billing and reimbursement expert to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regard to the finances involved in your medical care.

How Can You Qualify an Expert in Court?

Mon, 14 Jun 2021 10:47:00 GMT

If you are trying a case that has any complicated factors, such as medical malpractice, forensic accounting, or information technology, it will likely be beneficial to have an expert in the field testify on the facts of the case.

This doesn’t mean you can just ask your Aunt Martha who is a system administrator at her company to talk about firewall security. When you have an expert witness testifying in your case, it means that the issues are complex enough that an ordinary person would have a hard time making sense of the facts. The report prepared by an expert witness takes these complicated facts and draws a conclusion that a layperson (what the jury is likely made of) can understand.

There is a process to verifying or “qualifying” an expert witness for testimony, and it is important to know what that process is, and what is expected of your expert.

What is an Expert Witness?

An expert witness is a professional in their field, usually related to medicine, finance, technology, security, or other fields where an individual would have specialized knowledge that would help them weigh in on a case. An important distinction of expert witnesses is the fact that they have expert knowledge of a particular type, and it is not something that a layperson would be able to establish. Furthermore, an expert witness must testify on something very narrow in scope, and cannot simply be a generalized expert in their field. A medical billing expert called in on your case would have to testify on the accuracy and reasonableness of charges for your medical bills, or, the various codes used to report your care to insurance. They could not testify broadly on medical billing in general.

What is Voir Dire?

Literally translated “voir dire” means is to “speak the truth,” but it generally is used to the process at trial when either the judge or the attorneys ask questions of potential jurors so the attorneys can determine who they wish to keep on the jury panel at trial. It is also the process used to qualify an expert witness as an expert in his or her field for purposes of a trial.

For example, if you need a medical billing expert to testify in your injury case that the treatment you received after an accident was medically necessary, then they will be asked a series of questions by both the party offering the witness (you or your lawyer) and a cross-examination by the opposing party to establish them as someone with the background and expertise necessary to “qualify” them as an expert.

Often the requirements for being considered an expert are a combination of educational, practical and experiential factors. When presenting an expert witness it is important that they have been well-schooled in the area that they are testifying about, that they have continued learning about the subject in the years since formal education, and that they have work experience in the field.

Rules of Evidence

The rules of evidence specifically related to expert testimony provide for what an expert witness is allowed to do in court. Because they are preparing a report for the case that is based on the evidence given to them by their side in the litigation, their testimony can make the difference in convincing a jury one way or another because they are offering a conclusion on how the trial should be adjudicated. There multiple ways an expert can offer a testimony:

1. The specific knowledge of the expert will help elucidate evidence in the trial or determine a fact.
2. Their testimony is formed upon “sufficient” facts.
3. The testimony is produced from methods and principals, or
4. The Expert used methods and principals and applied them to the case at hand.

Because of these rules, it is always important to ask your expert witness to prepare a report before the trial and admit it into evidence. It is also necessary for the expert to re-familiarize themselves with the contents of the report shortly before the trial so they are aware of its contents and their references during the cross-examination. Some expert witnesses will require coaching on how to handle themselves in the courtroom to avoid conflict and stick to the facts.

What an Expert Witness may be asked during voir dire :

1. Their name
2. Their occupation/place of work
3. How long they have worked there
4. What degrees they have earned and from which institutions
5. Any professional societies of which they are members
6. Any awards they have received related to the area in which they are experts
7. Any licenses/board certifications they possess
8. Do they perform scientific studies/publish peer-reviewed works
9. If they prepared a report
10. What materials they used to prepare their report
11. The conclusion they reached in their report

There are more relevant questions an expert witness may be asked, including if they continue to do research, or if they have a resume (if they do have a resume, it should be admitted into evidence with their report). The most important thing when qualifying a witness is to present them as an expert in a narrow field on which they are testifying and that they answer each question directly and honestly.

Why You Need Medical Billing Analysts

It is highly recommended to hire a medical billing expert to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regard to the finances involved in your medical care.

What is a CPT Code?

Mon, 07 Jun 2021 14:41:00 GMT

Say that you’re a responsible adult who has health insurance, either independently or through a corporation, and you make an appointment for an annual physical. You go to the doctor’s office, you pay your co-pay, and you get poked and prodded. You either lie about how much you’ve been exercising or agree that you need to do more, and are sent on your way.

A little while later, you get a letter in the mail from your insurance company that says it is not a bill, it is an explanation of benefits, with the amount your services cost, and how much your insurance paid. But how do they get that information? Your doctor’s office used a series of standardized codes to inform your insurance company what they did so the doctor’s office can be reimbursed for their services.

In this article we are going to talk about what those standard codes – CPT codes – really are.

What does CPT stand for?

CPT stands for “Current Procedural Terminology” and there is a code assigned to everything that a doctor’s office might do, from surgery and lab tests to office visits and vaccines.

What does a CPT code look like?

CPT codes consist of 5 digits, sometimes they are five numbers, and sometimes they are four numbers and one letter. Because these codes are uniform across the healthcare industry, they standardize the method of tracking your care between providers.

How do medical billing experts know what code to use?

To ensure that these codes are the same, they are managed by the American Medical Association and the medical billing experts at your provider’s office will use them to record your care. Sometimes these codes are changed, some are added for new items, and old ones are removed. There are many thousands of different codes, and the standard codes are updated on a yearly basis.

CPT Codes and Billing

Just because the codes used to standardize the notation of medical services are the same across the healthcare industry, it does not mean that your provider has the same agreement with your insurance that another provider does. Where one provider may be reimbursed $50 for a service, another may only be reimbursed $40, leaving you to pay $10 more to them after insurance takes care of their part.

Some CPT codes are for what is called “bundled services” or services that are typically performed at the same time and therefore have been included as a single code. For example, this can be the individual codes that make up the service of receiving a vaccine: the service itself (the injection), the reason for receiving the injection, how it is administered, and what is being injected. The service of how a medication is administered by injection will appear in multiple bundled codes for things like a flu vaccine, local anesthesia, steroids, etc.

One of the problems with bundled codes is that sometimes the individual services within a bundled code can be listed separately, leading the patient to pay more. Sometimes this is accidental, and sometimes it is the result of deliberate up-charging to commit fraud. There is even a special term for this called “unbundling” when bundled codes are split out and billed individually.

Additionally, if services outside the bundled code are required, it can cause problems known as “upcoding” or, services are billed for more than they should be. For example, anesthesia for surgery may be billed as a more complicated procedure or if it was performed by a doctor it is more than if it was done by a nurse.

Medical Billing Process

The medical billing process begins in your provider’s office where they or their assistant will enter the CPT codes—or HCPCS codes (Healthcare Common Procedure Coding System) if you have Medicare—that correlate to your care. This is either done electronically, or manually on paper forms.

Once the codes have been entered, they are verified by a medical biller and the correct code is assigned if it has not been already, then it is submitted to your insurance company. Most of the time this is done electronically, though there are still some holdovers using mail or fax machines to submit billing to insurance.

Your health insurance company, based on the plan you have, will use the codes provided by your doctor’s office to process your health claim and pay the provider for services rendered, and the remainder will be what you have to pay to your doctor.

The health data collected by your providers is used by your health plan and government agencies to determine future healthcare costs. Future healthcare costs are of particular importance to individuals if they have experienced an accident or injury that will require ongoing care and they need to argue for damages.

If your medical bills are much higher than you expect them to be, contact one of the medical billing experts in your region to look over your bills and see if there is anything out of place.

Why You Need Medical Billing Analysts

It is highly recommended to hire medical billing experts to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

Medical Billing Analysts offers litigation support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represents both defendants and plaintiffs with regard to improper medical billing and coding.

The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses, and based on local CPT codes they can also perform a Cost Projection Analysis of future costs . Through meticulous analysis, we can justify the reasonable cost of services which assists in resolving the case.

What Does “Medical Necessity” Really Mean?

Mon, 31 May 2021 12:38:00 GMT

The purpose of health insurance is to reimburse doctors, hospitals, and caregivers for the services they provide. The way that is accomplished logistically is based on a series of codes submitted from the providers’ offices. After insurance pays their portion, you may still owe your providers money, based on the type of plan you have, and whether you paid co-pays upfront or you have a deductible.

Sometimes, however, insurance will refuse to reimburse providers for services they consider elective, experimental, or not medically necessary . In this article, we are going to discuss what the term “medical necessity” really means for health insurance. Specifically, we will cover whether items like cosmetic surgery are truly medically necessary.

Cosmetic Surgery

Procedures that are undertaken for the express purpose of altering the patient’s body for aesthetic reasons are what we commonly think of when we hear the term “cosmetic surgery.” For example, cosmetic surgery could be breast implants, rhinoplasty (nose jobs), and botox injections.

Any time that a patient is under general anesthesia, there are risks of long-term impact on their health. Consequently, insurance does not pay for surgery that is not medically necessary.

However, reconstructive procedures may be covered by insurance. Insurance may pay to restore a symmetrical appearance after a mastectomy to remove breast cancer, or surgery to reduce scarring after an injury accident.

Botox is widely known as a cosmetic treatment for the appearance of facial wrinkles. This is because botox blocks chemical signals from the nerves, typically the nerves that cause muscles to contract. As a cosmetic procedure, this helps relax the muscles that contract the forehead and eye areas.

However, in recent years botox has been used to treat other conditions related to nerve signals, including lazy eye, chronic migraine, and bladder incontinence. Billing experts can help you determine how procedures were submitted to insurance, and the likelihood you can appeal a denial to your insurance company.

Because this use of Botox is a new treatment, some insurance will consider it “experimental” and will elect not to cover it. Read below for more about experimental treatments.

Pre-Authorization

If you have a plan that requires you to get referrals for your treatment, determining if a procedure is medically necessary is particularly important if a provider out of your insurance network is involved in your care.

Even if your doctor determines that a procedure is medically necessary if it will be an expensive procedure it is worth reviewing your policy and calling your insurer to make sure of the rules. If a procedure that is not a result of emergency care is performed without prior authorization, insurance may deny the claim. You can appeal this to your insurance company, but you may have a difficult time if you have not followed the rules put in place by your insurance policy.

A medical billing expert can help you sort through the often-confusing world of codes and procedures and determine if there were any errors on the provider’s side causing an insurance denial.

Experimental Treatment

Experimental treatments are most commonly drugs or vaccines that have not yet been approved by regulatory bodies for widespread use. Vaccines like the treatment for Covid-19 which are approved for emergency use by the FDA are considered experimental until they receive full approval, in which time side-effects may be discovered in the wider population.

The use of medical cannabis is another case in which the treatment is considered experimental. The FDA has not approved the use of marijuana for treating medical conditions. Despite more than 30 states legalizing the use of cannabis for medical conditions, it remains illegal at the federal level and classified as a schedule I drug. This is the most restrictive tier of classification and is characterized by being considered to have no medical use and a high potential for abuse.

It has been impossible for the FDA to approve the use of medical marijuana because the restrictive nature of the Drug Enforcement Administration’s classification prevents extensive trials for the purposes of determining the safety of use and the efficacy of use for marijuana.

All of these factors: the restrictive DEA classification declaring “no accepted medical use,” the lack of FDA approval, and current federal illegality mean that health plans will not cover the use of medical marijuana, even if your doctor determines it is medically necessary and it is an effective treatment.

Determining Medical Necessity

Whether a procedure is considered medically necessary can change depending on whether or not you are insured by Medicare or private insurance, and the region in which you receive your treatment can influence the approval as well.

For example, there are National and Local Coverage determinations and private Medicare plans that do not always agree with each other. Furthermore, private insurance companies can set their own standards.

A medical billing expert in your area can help you determine what is considered medically necessary by these local coverages and the interpretation of your healthcare plan.

Why You Need Medical Billing Analysts

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regard to the finances involved in your medical care.

The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses, and based on local CPT codes they can also perform a Cost Projection Analysis of future costs . Through meticulous analysis, we can justify the reasonable cost of services that assists in resolving the case.

What is an Insurance Rebuttal Letter?

Mon, 24 May 2021 09:30:00 GMT

If your medical claim is denied, that isn’t the end of the process. You can appeal a denial if your treatment was deemed medically necessary, or if there was an error and your insurance company has denied something that they shouldn’t have.

If you checked to make sure your provider and treatment were covered, yet you are still get billed because a provider who is out of your network assisted with your treatment. This is the time to file an appeal. Read below for advice on appealing your denied claim.

Understand Reasons for Denial

There are many different reasons that your insurance company could deny the claim submitted to them. The provider you saw might be out of your insurance network, they may have not given the correct information to your insurance company or a clerical error could have occurred. Sometimes health insurance companies make the determination that the procedure you received from the provider was not medically necessary.

The most common of these reasons is a clerical error. If the billing codes entered at the doctor’s office are incorrect, it can result in a denial from the health insurance plan. If you believe this has happened to you, it is valuable to have a medical billing expert look at your bills to see if it was billed properly. Of course, after you verify that it was billed properly, you still have to make sure that your plan covers the procedure.

Know What is Covered by Your Policy

Health insurance plans are different, and what is covered by one is not covered by another. Even if you think you know how your co-pays work and how much of your treatment should be covered, you should still read through your policy to be sure of what it covers before you write a rebuttal letter . In fact, if you know that you need regular medical treatment, you should have a copy of your health insurance policy easily accessible so that you can review it in cases like this. If you have a policy through your company and you can’t find a copy, your HR department should be able to help you obtain one.

Call your health insurance if you have any questions about your billing, and make notes of the date and time you called and who you spoke to.

Find Out the Reason Your Claim Was Denied

When you receive medical care and billing is submitted to your insurance company, you should receive an explanation of benefits from your insurer. This may be sent to you in the mail or you may receive it electronically, depending on what you have selected to receive from your healthcare provider.

The explanation of benefits will usually say “This is Not a Bill” on the front page, and proceed to break down the cost of the treatment, how much the insurer paid, or why it was denied. A billing expert can look at what treatment was listed and determine if it was submitted correctly.

Gather Your Documentation and Write Your Appeal

The most important piece of documentation from your provider will be something called a “letter of medical necessity” particularly if your claim was denied because your insurer made the determination that your procedure was not necessary to your treatment.

If you need to provide more evidence to your insurer that the treatment was medically necessary, try to find verified studies (peer-reviewed) that are in line with your assertion that the procedure was necessary. Also, if you got a second or third opinion when you were seeking treatment and your providers recommended the same thing, you can use this as evidence.

Make sure your treatment was billed appropriately. For example, a surgery to fix a condition may be denied by your insurance company, but the underlying condition requiring the surgery is covered. You have to make sure that the information was adequately transmitted to your insurance company so they have all the information to review your case. Medical billing is a complicated field, so it may be worth having a billing expert look over your claim to make sure it was handled appropriately.

When you write your letter, it should be straightforward and to the point. Don’t delve into the emotional ramifications of the claims process, provide the facts of the situation and why your treatment should be covered. Include the necessary information for the insurer to know who is being talked about: Name, address, date of birth, insurance identification number, and date the services were provided.

Make sure you start the letter by stating that you are appealing a claim that was denied. In the body of your letter, explain (based on the evidence you collected) why the bill should be paid.

Send your letter by certified mail so you know it was received, then follow up with your insurance company 7 to 10 days later to check on the status of your appeal.

File Your Rebuttal in the Necessary Timeframe

Read your policy to understand the time limits for filing an appeal. Don’t leave it to the last minute because you will need to get documents from your providers, and there will be a time delay for that as well.

If there are many different pieces to your case and you are concerned that the deadline will pass before you can gather everything necessary to make your appeal, write your insurance company a letter and say you are appealing their denial, and are sending more information. Follow up promptly after buying more time.

Why You Need Medical Billing Analysts

It is highly recommended to hire a medical billing expert to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses, and based on local CPT codes they can also perform a Cost Projection Analysis of future costs . Through meticulous analysis, we can justify the reasonable cost of services which assists in resolving the case.

Preparing an Expert Witness for Testimony

Mon, 17 May 2021 08:59:00 GMT

If you are going to trial and relying on the testimony of an expert witness in your case, you will of course need to prepare them for their testimony, even if they have testified many times before. Here are eight steps for a good prep of your expert.

Give the Expert the Facts of the Case

Be sure your expert witness knows all the facts of the case. This may seem obvious, but oftentimes opposing counsel can use it to their advantage if the expert is unsure of certain, more obscure, facts. The expert who is testifying needs to be as knowledgeable as the attorney, otherwise, there may be push back during cross-examination.

Give Your Expert Time to Prepare Their Testimony

Again, this may seem like an obvious piece of advice, but the closer it gets to the date of the trial, the more attorneys try to pack everything possible into their schedule. It is imperative that your expert is given the opportunity to review relevant documents ahead of time, and that they go back and look at their report again, so they are ready for trial.

If the expert prepared their testimony months in advance, there is a chance that they will forget what is in it and opposing counsel can use that to undermine their authoritative position.

Show That Your Expert is Still Learning in Their Field

Someone who is still working in the field about which they are testifying will have recent and relevant knowledge they can draw upon to provide their testimony. An active medical billing expert is constantly updating their knowledge base of billing codes and procedures.

If your expert has retired a long time ago, their testimony may carry the weight and wisdom of age, but you run the risk of having the jury perceive them as someone whose expertise is out of date.

Slow, Loud, Smile

These three things will make your jury more receptive to what your expert is saying because they will be a more engaging and interesting speaker. By speaking slowly, the expert can show that he is engaging with his listeners and making sure that what he is saying is connecting with his audience. Speaking loudly does not mean shouting, instead, make sure that the expert is energetic and “in the moment” delivering their testimony.

Lastly, smiling is such an easy thing to do to not only put members of the jury at ease but also to communicate enthusiasm for their subject matter. Someone who is excited about what they are talking about will make an impression on the jury.

Communicate in the Most Effective Way Possible

The reason it is called expert testimony is that sometimes the issues at hand are very complicated, regardless of whether it is a piece of technology, a process, or complex accounting. The more obscure the issue at hand, the more work the expert will have to do to elevate the listeners by using examples, visual aids, and explanations.

Have the expert watch the reactions of the jurors for signs they are losing interest, and if that happens, have them ask for permission to move about the courtroom to show an example. The movement will re-capture the attention of the jury.

Remember the Perspective of Someone Who is Not an Expert

One of the most important things you can do when helping to prepare your expert witness is to get them into the shoes of the jurors. Most likely, there will not be people on the jury who have an understanding of what the expert is talking about (but if there are, that is its own danger, addressed below).

If the expert is caught up in the technical complexity of the interactions between the lawyers, they may lose the perspective of simplifying their topic so an average person can understand it.

Identify if There Are Experts on the Jury

When jurors are knowledgeable in an area related to the issue at trial, it can cause problems for the attorneys. For example, if there is a doctor on the jury, they may be less likely to consider the expert testimony if it is for medical malpractice. Worse, they can influence the rest of the jurors either consciously or unconsciously by revealing this knowledge and their opinion on the expert testimony, so juror selection is particularly important in such cases.

Discourage Conflict with Opposing Counsel

Sometimes experts take the questioning from cross-examination as a personal attack and engage in fighting with the other attorney. Feeling the need to somehow “prove” themselves, they may become defensive or avoid answering questions by turning the questions back on the other attorney.

The best thing you can do is equip your expert to redirect confrontation and stay calm while continuing to educate the jury throughout the cross-examination.

Why You Need Medical Billing Analysts

It is highly recommended to hire a medical billing expert to determine and provide expert testimony as to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses, and based on local CPT codes they can also perform a Cost Projection Analysis of future costs . Through meticulous analysis, we can justify the reasonable cost of services which assists in resolving the case.

What is Important About the Concepts of “Reasonableness and Necessity”?

Mon, 10 May 2021 08:10:00 GMT

In a personal injury case, the reason for paying damages to an injured plaintiff is to compensate them for losses caused by the responsible party: the defendant. Because of this, the law holds that the responsible wrongdoer is accountable for paying the necessary medical expenses that the injured party had to pay. Without the wrongdoer’s negligence or failure to act, the injured party would not have needed to receive treatment and recover from the incident.

However, the requirements for admitting medical bills into evidence for personal injury cases are often misunderstood, even by the attorneys who are representing the interests of their injured clients. The first step in admitting medical bills is authenticating them, and there are four ways this can happen: Stipulation, Testimony of Custodian Records, Affidavit from Provider’s Custodian of Records, or Lack of Objection during disclosure.

Medical Bill Coverage

To recover medical expenses, a plaintiff must provide evidence of what they paid for their medical treatment. Regardless of whether it was a car accident, a workplace injury, or a slip and fall, the treatment must be documented in order to be compensated.

This means that all medical billing must be accounted for, including but not limited to the bills for an ambulance ride, hospital stay, X-rays, lab tests, surgery, and anesthesia, follow up doctor’s appointments, prescriptions for pain medication, physical therapy, and nursing care as a result of treating the injury.

It is also a requirement to prove that all of the expenses were necessary for the course of treating an injury incurred by the defendant and reasonable in cost. An expert witness is required to give testimony to prove that medical treatment was necessary.

A plaintiff may also be required to produce medical billing evidence that the medical treatment received was a standard procedure and not an experimental one. Also, they need to show that the treatment was both appropriate for the circumstance and not fraudulent so the bills can be admitted as evidence, and they can be considered by the judge or jury to help determine the defendant’s obligation to pay.

“Reasonable and necessary” are also terms frequently used in auto and health insurance policies to require the policy to pay for medical expenses and limit the payments to just the medical bills which are both reasonable and necessary. However, oftentimes these terms are poorly defined.

Medical necessity means that the treatment was required to help the patient recover as a result of injuries from their accident, not a treatment for another condition. This gets complicated when injuries the plaintiff claims aggravate medical conditions they already have, such as arthritis, or if the plaintiff has been the subject of an injury before.

Sometimes lay testimony is accepted instead of expert medical testimony if the plaintiff gives a detailed description of the treatment and relates them directly to the injuries from the accident. This is not acceptable in all jurisdictions.

Collateral Source Rule and Why it Matters

This depends heavily on what state you are in. Some states maintain that a defendant can benefit from write-offs or other adjustments made by insurance to what the provider charged for treatment. Other states have what is called the Collateral Source Rule. The idea of the Collateral Source Rule is that the defendant should not have the benefit of payments made by insurance that the injured party obtained independently and pays premiums for.

Some states adopted the collateral source rule and still give the defendant the write-off benefit, with the argument being: The plaintiff would receive a windfall if they were compensated for the amount that was written off, No Collateral Source paid the written-off amounts, and Written off amounts are not real medical expenses because the plaintiff didn’t have to actually pay them.

However, that argument doesn’t address the fact that the injured plaintiff has to pay for their insurance coverage in order to have those amounts written off in the first place, which is part of the reason for the collateral source rule.

Under the Collateral Source Rule, the plaintiff is still required to prove that the medical charges were reasonable and necessary, however, the expert witness is not always required to be a doctor. A medical billing expert or a nurse who is familiar with customary charges may be accepted as an expert medical witness.

A defendant is only required to pay for the reasonable medical expenses necessary for treatment, not always the whole amount billed by providers. In cases where the plaintiff does not have a medical expert, they call every doctor who provided care as a witness. If a doctor referred the plaintiff to another, the referring doctor can testify that the treatment given by other practitioners was necessary.

If the plaintiff is seeking to recover damages for future medical expenses, there must be expert testimony that there will be ongoing medical expenses from the injury, and a reasonable cost for those future services. If the future projection is for a long period of time, the requested amount must reflect the current value of treatment.

Why You Need Medical Billing Analysts

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

What is a Medical Lien?

Mon, 03 May 2021 07:29:00 GMT

Personal injury cases are always complicated because there is a fine balance that has to be maintained between making the responsible party pay for the damage they have done while avoiding a situation where the injured party receives an egregious amount of money. This is particularly important if an extensive amount of medical treatment was necessary on the part of the injured party, and they had health insurance that covered the cost of their care.

Shouldn’t the person responsible for the damage be made to pay for it? Yes, but the injured person had medical insurance and they didn’t have to pay out of pocket for their treatment, why should they receive that money when it was not a cost they had to bear? Can’t the plaintiff sue the party who injured them for those amounts anyway?

Medical billing is a minefield of questions. How much was the cost of care? Was the cost of care reasonable? Do the treatments the patient received line up with what is reasonably considered standard treatment for the injuries they received?

In this article, we will discuss in detail the responsibility of repayment for medical services after an accident, also called “medical liens.” We will also cover how medical liens can impact the settlement payout in a personal injury case. If you have more questions after reviewing this article, then contact the professionals at Medical Billing Analysts.

How Do Medical Liens Work?

A medical lien is any demand for repayment for medical services that can be placed against the settlement money paid out in a personal injury case. For example, if someone is injured in a car accident and their medical insurance pays for the cost of all of their treatment after deductibles, the health insurance company can put a lien against the settlement.

The argument is that even though the individual was injured, the health insurance company paid for part of the medical care. Therefore, instead of the individual receiving the amount of money covering the cost of the treatment, it would go to the insurance company instead.

When a health insurance company issues a lien to cover the amount they paid for the medical billing in your recovery, you or your attorney may have to go through a process called “subrogation” in order to pay it back.

The length and complexity of subrogation claims varies from state to state and depend heavily on how your health insurance policy is worded. So, if this is a situation you find yourself in, make sure you talk to your lawyer so you know what to expect.

Can You Sue For Medical Bills Paid By Insurance?

The short answer is yes. However, it is a little more complicated than just saying that you can sue the responsible party for the cost of your medical treatment.

This is a situation where it is helpful to have a medical billing professional review the bills and the cost of your treatment to determine what the value of your treatment was. Regardless, the fact of the matter is that you are unlikely to be directly paid for the cost of your medical care because the insurance company is the party that ultimately spent the money for it.

Types of Liens

There are a few different kinds of medical liens that you might commonly see in your personal injury case. They can depend on the state you live in as well.

1. Hospital Liens

In some states, the hospital that provided your medical treatment following an accident has the right to file a lien for repayment of any expenses related to your care.

Some medical providers, when you receive treatment, ask you to sign a lien letter. The letter essentially states that you submit to a lien against any future personal injury settlement, and to be considered valid must generally adhere to a strict set of statutes.

2. Government Liens

This includes Medicare, Medicaid, Veteran’s Benefits, etc. If the government paid for your healthcare in any capacity after you suffered an accident, they have the right to recover that money if you are involved in personal injury litigation.

Liens and Attorneys

Talk to your attorney about the possibility of a medical lienholder accepting less than the amount they paid for your care while still releasing you from the lien (the responsibility to pay them back).

This is particularly important because your attorney will also take a portion of the settlement for their fee.

For example, if you agreed to pay your lawyer a third of your settlement, you could still owe a quarter of the total settlement in medical liens, leaving you with less than half of the settlement amount in your pocket. Medical billing is a key part of understanding what kind of lien you are looking at when handling your personal injury settlement.

Why You Need Medical Billing Analysts

Medical liens can complicate an already complicated process. Accordingly, it is highly recommended to hire a medical billing and reimbursement expert to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses, and based on local CPT codes they can also perform a Cost Projection Analysis of future costs . Through meticulous analysis, we can justify the reasonable cost of services which assists in resolving the case.

How Can an Expert Witness Help Your Client’s Case?

Mon, 26 Apr 2021 07:29:00 GMT

There are no two cases exactly alike. Therefore, each case requires its own handling of facts that are relevant to the argument at hand.

The experts for each case are almost as varied as the types of lawsuits that exist. The benefit of hiring an expert witness will vary from case to case and depends on whether the hiring party is the prosecution or the defense.

When you hire an expert witness, it means that you are calling in someone with a deep understanding of the case’s material to weigh in during litigation. Because having testimony from an expert witness can sway the outcome of a case, it is important to have a good one on your side if you choose to use one.

But what does having an expert witness mean, and what are their responsibilities in the case? In this article, we are going to discuss the utility of the many different types of expert witnesses, including Forensic Experts, Vocational Experts, Financial Experts, Medical Experts, Medical Billing Experts , and more. If you are considering including a professional who is an expert in their field giving testimony in the case, read on below for more information about using expert witnesses.

What does an Expert Witness do?

Expert witnesses are commonly brought into a case to explain exhibits or provide a perspective on a subject that a layperson would not normally know about. They testify in a trial in an area where they are knowledgeable and usually a working professional.

That is, as you know, what makes them an expert. It is because they are knowledgeable about a subject that is “beyond the ken” of the average person. Thus, anyone who has specialized knowledge in a particular field can testify as an expert.

Also as you know, experts typically do not need to discuss the specific facts of the case. Rather, experts speak in hypotheticals that touch upon but do not directly address the facts of a particular case.

Advantages of Using Expert Witnesses

Aside from the fact that an expert professional will provide an extremely knowledgeable viewpoint in a case, there are other advantages to hiring an expert witness.

Experts have the credibility of experience . They deal with the subject matter they are discussing on a daily basis and are intimately familiar with it. They can offer the kind of insight a legal professional, or lay witness does not have.

Experts project an air of impartiality . Typically, experts have an ethical responsibility in their field of expertise. Thus, a witness who must follow a code of ethics has credibility because he or she needs to be objective.

Experts provide a fresh perspective . A lot of times, our confrontational justice system puts focus on the fight, rather than the facts. Thus, expert witnesses can be very helpful to your case in re-focusing the judge or jury where the attention belongs – on the real facts and circumstances of the case. Solid reasoning from an expert supersedes tons of passionate arguments every time.

Types of Expert Witnesses

There are multiple categories of experts who are typically asked to provide testimony in a case, and more than one can apply when you are dealing with a personal injury case.

1. Medical Expert Witness. These are the most common types of experts called in for medical malpractice suits or personal injury suits. They have experience in the medical field and can speak to the severity of the injuries sustained or the degree of the malpractice which occurred.
2. Financial Expert Witness. These are specialists who deal with money and may be called upon when there is an issue related to accounting or fraud.
3. Forensic Expert Witness. These expert witnesses offer insight into the details and logistics of a case, often involving ballistics and blood spatter to determine how a crime occurred.
4. Vocational Expert. This is someone who can weigh in on whether someone is able to resume their job duties and their capacity to do so.
5. Mental Health. The capacities of a mental health expert witness are similar to a medical expert witness, but they are more likely to determine whether a person is stable enough to stand trial.

Let’s Talk Specifically About Medical Billing Experts

A Medical Billing Expert is someone who is somewhere between a Medical Expert and a Financial Expert, because they have to be familiar with details of both for their job.

Particularly in cases of personal injury, medical billing experts are called in to help establish a basis for the cost of medical treatment the plaintiff required and if there are any ongoing costs the responsible party needs to cover as part of the settlement.

Typically, a medical billing expert will review the hospital bills, insurance reimbursements, and medical records to provide a comprehensive analysis of whether the medical costs were reasonable, and whether they can be used to determine future costs.

Why You Need Medical Billing Analysts

It is highly recommended to hire a medical billing and reimbursement expert to determine and testify to the reasonable value of medical services.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses, and based on local CPT codes they can also perform a Cost Projection Analysis of future costs . Through meticulous analysis, we can justify the reasonable cost of services which assists in resolving the case. Contact Medical Billing Analysts by phone or email at 800-292-1919 or intake@medicalbillinganalysts.com .

What is the Collateral Source Rule?

Mon, 19 Apr 2021 09:47:00 GMT

If your client is injured in a car crash, does the amount your client receives from an insurance company reduce the amount he can receive in compensation from the negligent party who hit his car?

That question is answered by something called the Collateral Source Rule . In this article, we are going to discuss precisely what the collateral source rule is, and then give some recent developments on that legal concept. If, after reading this article, you have additional questions about this or any other insurance billing issues, we welcome you to contact Medical Billing Analysts by phone at 800-292-1919 or intake@medicalbillinganalysts.com . We’re here for you and your personal injury clients.

What Is the Collateral Source Rule?

The Collateral Source Rule stops an injured person’s personal injury damages from being reduced by payments that he or she received from their own medical insurance, workers’ compensation, or other sources. In other words, the rule avoids a reduction in damages solely because the person received money from a “collateral source.” Thus, in an injury case, any monetary compensation received by the injured party (plaintiff), from anyone other than the legally responsible party (defendant) will not reduce the total recoverable damages from the defendant.

This issue typically comes up when the injured party has health insurance and his or her insurance company pays for all or for part of the cost associated with medical treatment for the injuries the plaintiff sustained. The injured person can be compensated by their insurance company and the defendant under the Collateral Source Rule, and medical billing review will determine if the cost of treatment was fair and reasonable for the patient’s region.

Other Collateral Sources

Health insurance is not the only situation in which the Collateral Source Rule comes into play in a personal injury case. Other collateral sources can include Social Security benefits, Medicaid benefits, and as noted workers’ compensation payments (if the injury occurred in the workplace). The Collateral Source Rule even covers any monies received from friends or family members who are helping to mitigate any of the damages.

Doesn’t the Rule Allow Double Recovery?

There is a debate on whether the Collateral Source Rule should be permitted in personal injury cases. Some argue that ensuring that money from collateral sources does not change the amount a defendant should pay in damages is a form of double recovery for the same injuries.

However, the rationale behind the Collateral Source Rule is one of deterrence. It would be unfair to remove the financial burden from the at-fault party simply because the plaintiff happens to have good insurance. Moreover, it would be unfair to other defendants if they happened to cause injury to someone who has no access to other sources of money. Thus, the Collateral Source Rule takes the issue of other sources of money out of the equation altogether.

The Collateral Source Rule in Practice

Suppose that, through negligence, a car was left on an incline without the parking brake engaged. It then rolled down the hill into another vehicle as it was making its way through an intersection. The driver of the vehicle that was hit suffered severe injuries costing $50,000, and his damaged car was a total loss.

For the purposes of understanding the Collateral Source Rule, suppose that the injured driver’s health insurance covered the full $50,000 cost of medical treatment, and the injured driver’s parents bought him a car as a replacement for the one they lost.

The injured party in this case can still sue the responsible party for the full $50,000 of medical treatment, and the value of the totaled car as property damage. Moreover, the jury will not hear about the payments made by the insurance company or the gift of a car from the injured party’s parents.

Collateral Source Rule Reform

Some states have taken measures to modify the Collateral Source Rule in some cases. In California, for example, the amounts that an injured party receives from health insurance due to medical malpractice will be admissible in evidence in a medical malpractice lawsuit. Yet, California also will allow a plaintiff to claim the amount of money he or she paid in order to get the medical insurance coverage in the first place. Thus, California’s modification of the Collateral Source Rule is relatively limited.

The State of Florida takes a different approach. In Florida, evidence of insurance payments is prohibited, pursuant to the State’s Collateral Source Rule, yet Florida will allow a defendant to introduce evidence of monies that an injured person received from government benefits. Also in Florida, a damages award can be reduced by the amount that an insurance company is owed if they initially wrote off part of the medical expenses.

In sum, the Collateral Source Rule is something that you need to be aware of when litigating personal injury matters for your clients. In that regard, Medical Billing Analysts can work side-by-side on medical billing review to determine the amount of medical billing that is reasonable and necessary.

Why You Need Medical Billing Analysts

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses and based on local CPT codes they can also perform a Cost Projection Analysis of future costs . Through meticulous analysis, we can justify reasonable cost of services which assists in resolving the case.

The Challenge of Establishing Past Medical Expenses – With and Without Insurance

Mon, 12 Apr 2021 17:29:00 GMT

If you were injured and had no medical insurance, the liability you have for your medical treatment is much higher than it would be for someone who was covered by health insurance. When you are going to trial to argue for economic damages, you need to prove that you are owed reimbursement for the medical bills you incurred, but that can be tricky to do when services were not submitted as claims to an insurance company.

As long as you have the medical bills that you were sent after your treatment was completed, there is hope. But, you have to be able to show that what your doctors charged you is a fair rate in order to be paid.

You should talk to your lawyer about what the best strategy is for your case, but planning ahead is the most crucial part of your injury case. In this article, we are going to provide key components to making sure your medical bills count for your side in the case.

Billed Amounts and Why They Are Relevant

When you have medical insurance and you require treatment, you are first handled by a provider of services. Then, a claim for reimbursement is submitted to your insurance company.

Because of the way health insurance works, there are things that your plan will cover completely and there are things that they negotiate discounts for. So, even if you had a treatment that is not covered, it is possible that you still do not have to pay the full value of the service.

Only after insurance has paid what they cover and negotiated discounts are accounted for, a bill is issued to the patient by the provider for the remainder of the difference between the cost of care and the insurance reimbursement. People who work in Medical Billing Services deal with claims all the time and are familiar with how much certain services cost in various areas around the country, but a provider may not.

When someone who is uninsured undergoes treatment, they are responsible for the full cost of the care provided to them, but this is where things get tricky. It is not always possible to use the full amount billed to establish “reasonable cost” for treatment, and sometimes having an expert on the subject testify is rejected by the court, so what do you do?

Admissibility

Billed amounts are not always considered “inadmissible.” Thus, to establish the reasonable cost of services, you have to be careful in the way that the billed amounts are presented.

Anyone who has to seek medical treatment as a result of injuries takes on liability for the cost of treatment, and therefore suffers a loss economically because insurance does not cover all of the cost of treatment. Reasonable charges that the patient still owes can be recovered in an injury case in the form of economic damages, however, the key word is “reasonable”

If the treating doctor is able to speak to the charges incurred as being a reasonable rate for the treatment provided, then it may be possible to establish that the charges are reasonable. Some doctors who work in a specialized field such as physical therapy are more familiar with the standard rates for treatment they provide than, say, a family medicine practitioner who deals with a wide variety of cases.

Burden of Proof

Have you ever heard: it isn’t what happened, it’s what you can prove? It is up to the plaintiff or the lawyer arguing on their behalf to prove what the reasonable rate for services is, in order to receive payment as part of the settlement in a case.

The defense lawyers in injury cases are very good at excluding both medical bills and the testimony of treating doctors. That is because the value of medical bills alone does not prove that what the patient was charged was reasonable. Furthermore, a treating doctor is not expected to be an expert in medical billing services, and therefore they may not know what the going rate is for treatments in their area.

If you rely solely on the unpaid medical charges, you will not have successfully substantiated the reasonable value of medical services.

Disclose Your Experts

If you are going to have an expert in medical billing services testify in your case, it is imperative that this is part of the pre-trial strategy. While treating doctors should be allowed an opportunity to speak to whether bills are reasonable as to the amounts that are within their knowledge, it is better to declare from the beginning that a particular treating doctor will testify.

As an additional strategy, it is best to have a disclosed expert in medical billing services review the medical bills and testify to the reasonableness of the unpaid medical charges owed by the patient. A medical billing expert will be able to take the U-C-R (usual, customary, and reasonable) rates for services in the patient’s geographic area and make a determination.

Why You Need Medical Billing Analysts

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

Medical Billing Analysts offers litigation support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represents both defendants and plaintiffs with regard to improper medical billing and coding.

What Goes Into Determining the Reasonable Value for Medical Services?

Mon, 05 Apr 2021 00:00:00 GMT

No one wants to think about their medical bills. The internet is full of anecdotes about the cost of medical treatment, to the point where some people have had Uber drivers take them to the hospital instead of an ambulance when they feel they are having an emergency.

But when you are the plaintiff in a personal injury or medical malpractice case, and you need to prove the amount you have paid for your care and the amount you need to continue to do so in the future, what do you do?

Medical billing specialists can help by reviewing the codes used by providers to denote the services provided, and they can even testify about how much you may owe in the future. Read on to find why enlisting the aid of medical billing specialists will benefit you.

How Is the Reasonable Value of Medical Expenses Determined?

UCR doesn’t refer to a college in California, it is the abbreviation for “Usual, Customary, Reasonable,” which is a three-part approach to determining the value of a medical service that has been provided, and what medical billing specialists use to determine if treatment was billed appropriately.

U – Stands for the “Usual Fee.” This is the amount that is usually charged by a medical provider for an item like a blood pressure monitor, or a service like bloodwork.

C – Stands for the “Customary Fee” and means that it is the fee that is typically charged by providers in the same specialty, who are also in the same geographical area, for an item or a medical service. This is typically a range that encompasses what other doctors in the patient’s area are charging for their services.

R – Stands for the “Reasonable Fee,” which is the rate for a service deemed necessary under the patient’s circumstances and conditions.

When used together, these terms “usual, customary, and reasonable” refer to the charges made by healthcare practitioners for any given medical service. Charges submitted to insurance are typically considered to be usual, customary, and reasonable if it falls in line with the average cost of that medical treatment within the patient’s geographical area.

These costs are calculated by the health plan administrator or the insurance company and must match the typical amounts charged for the same medical procedures within a specific medical community. Note that “community” refers to doctors, labs, hospitals, and other health care providers.

This information is used by your health plan and insurance company to decide how much they are willing to reimburse for a medical service in a given geographical area.

The Importance of Understanding the Future Cost of Medical Services

When arguing for a settlement in an injury or medical malpractice case, your plaintiff may have ongoing medical expenses for months, years, or possibly the rest of their life depending on the severity of the damage.

Knowing how much providers charge for their services, and thereby how much the patient will be responsible for, is key to knowing whether the offer by the other party is acceptable. The expenses for a severe car accident that leave a person unable to care for themselves demand far higher compensation than an accident which results in the loss of function for a single finger, for example.

Medical billing specialists will use the Usual, Customary, and Reasonable costs for medical treatment to determine the value of future medical costs so that you can argue from the best position possible for your client.

Medical Insurance and Why It Matters

When a plaintiff in a case is uninsured, it introduces some complications regarding the argument for medical expenses, because they are responsible for the full amount of treatment.

Insured plaintiffs are only responsible for the lowered amount which results after insurance has paid for a portion of the services rendered.

Unfortunately, for those without insurance, the full value of the initial medical bills is not sufficient to prove what their ongoing expenses will be. Rather, it is necessary to tread carefully with bringing in an expert to discuss the particulars of a medical billing situation.

Having an Expert Testify As To What Is Reasonable In a Case

In many cases, it is advisable to have an expert testify with regard to whether the expenses are reasonable.

This is especially valuable in cases where the treating doctor specializes in pain management or physical therapy and tends to be familiar with the billing codes of their chosen practice and to be aware of special circumstances which arise in their particular field.

Additionally, having medical billing experts testify separately as to the reasonableness of all the medical expenses can be beneficial because they are experts in medical coding and are intimately familiar with the usual, customary, and reasonable rates for treatment. If the medical billing specialists you choose have offices located across the country, they will be better prepared to assist you, as the cost for certain medical treatments varies by the geographical region of the patient.

Why You Need Medical Billing Analysts

It is highly recommended to hire a medical billing and reimbursement expert to determine and testify to the reasonable value of medical services. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

Medical Billing Analysts (MBA) offers litigation support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represent both defendants and plaintiffs with regard to improper medical billing and coding.

The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses, and based on local CPT codes they can also perform a Cost Projection Analysis of future costs . Through meticulous analysis, we can justify the reasonable cost of services which assists in resolving the case.

Why Should I Get Copies of My Medical Records?

Mon, 29 Mar 2021 06:05:00 GMT

Do you remember what happened when you needed to get a cast on your arm a decade ago, or how long it took you to recover?

That’s alright, with the pace of life, not many people are going to remember the details of their medical treatment. This is why doctors and billers use complex codes and keep records of the services provided so that they can be referred to in the future. But what happens if you need to provide your medical records to someone for legal reasons or if you are seeking a new doctor and they need to know your history?

Don’t be caught off guard by not having the information you need when you need it. Be sure to keep a copy of your medical history for your own records, and here are five reasons why:

1. Keep your records accessible

One of the biggest problems with medical records that are held at a doctor’s practice is that they are not accessible if you need them, particularly for a personal injury case. For example, you need your records if you need to demonstrate that you received treatment, or if you move and another specialist needs information on what your last provider did.

By keeping a copy of your own medical records, you can have the confidence that you won’t have to file a request and wait a long time to receive them when you really need them. Especially in a post-pandemic world, doctors and their staff are extremely busy, and it may take them a while to get around to sending the medical records to you.

2. Ensure the security of your records

When your medical records are held by your doctor’s office, you run the risk of them being unavailable to you after a set period of time. Some practices have policies that require medical records to be expunged or destroyed after a limit of anywhere from five to twenty years, depending on the practice.

If your doctor’s practice burns down or floods, you could lose access to valuable medical data, forever. It is worth having a copy of your medical records especially if you were involved in an accident or other incident involving an injury in order to demonstrate the care you received. Do not let an accident or theft destroy valuable data that you may need in the future, especially when you begin planning for future care.

3. Peace of mind

When you have copies of your medical records, you are in control. If your doctor sells or closes their practice, or if your provider decides to move, then you have no way of knowing if your medical records will be preserved or if you will be permitted to access them.

When you keep a second copy of your medical records in your home or in a safety deposit box, you know that you will always be able to get to them. If you keep them in your home, make sure that they are protected against someone else looking through them or taking them.

Specific laws were created to protect the information held in medical records because it is private and confidential. Wherever you decide to store your copies of your medical records, make sure that you take precautions for the security of the data in them.

4. Have a backup plan

Having your own copy of medical records is a smart decision, but your home is just as likely to burn down as an office building. There are many methods for digitizing paper records in the modern world and having an electronic copy that you can access may be beneficial to you.

A USB drive is a good way to store digital records offline and is a good backup to the paper records you will likely be provided by your office.

If you choose to use a cloud service to store your data, make sure you thoroughly review their security practices to make sure that your personal information will be safe and keep in mind that if they ever announce that they have a breach, your medical records could be in the hands of unscrupulous people.

5. End of life care

When you have a copy of your medical records available, it helps your doctors and loved ones create the best plan for your care when you can no longer get around on your own.

Having information about your treatment and your physical and mental condition will allow for comprehensive handling of your specific situation so that you can be comfortable with assisted living or in-home care. While it is up to you or your power of attorney who your records are shared with and to what extent, having the information already accessible is a great place to start.

Why You Need Medical Billing Analysts

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

Medical Billing Analysts offers litigation support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represents both defendants and plaintiffs with regard to improper medical billing and coding.

The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses and based on local CPT codes they can also perform a Cost Projection Analysis of future costs . Through meticulous analysis, we can justify reasonable cost of services which assists in resolving the case.

Don’t Be Scared of Medical Record Retrieval

Mon, 22 Mar 2021 09:54:00 GMT

Do you know the ins and outs of performing a medical record search? Are you worried about doing everything right if you try to take it on by yourself?

Even as an injury case specialist, it’s unlikely that you are prepared to deal with the particulars of filing a document search for your client’s patient records. Where do you even start?

You need the proof of the treatment that your client received after an injury or accident, but you know far more about the laws you will be arguing than the health care system.

You could pay in-house to have an intern or assistant track down each provider, from emergency services to the physical therapist your client saw during recovery, but that is a long and slow process. Why waste their time and your money when they don’t have the expertise necessary to get the job done?

It may be worth it for you to bring in a third party who specializes in medical record retrieval. There are companies out there that do this as their main form of business, and they have a track record of delivering results. Keep reading for four reasons why you should look into hiring someone to do medical record retrieval for you.

1. Leave it to the Professionals

These companies handle medical record retrieval on a regular basis. They know exactly what they want and how to ask for it, and they will deliver results when you need them.

When you get the records from a company that does the medical record retrieval, sometimes they will already be chronologically coherent for you. You save even more time this way because not only do you not have to search for the records on your own, but also you know exactly where to look for the dates of treatment. You don’t need to try and figure out where the records are hiding.

2. Narrow the Field

You don’t need to search through every physical and lab test in your client’s medical history when you are searching for information to execute their injury case. You only need to see the procedures related to treatment of the effects caused by the accident, but how do you know what you’re looking for?

You need to have someone skilled in medical record retrieval to get the data for you, otherwise you may end up with that entire history mentioned before as a stack of papers you have to comb for details, and it’s just more clutter that is taking up space in your office.

Using a company specialized in medical record retrieval will let you to focus on only what you need to properly argue your client’s case.

3. Outsourcing Saves You Time and Money

Companies that do medical record retrieval have fees for their services. Everyone in business does, but the requests should have some consistent fees so you can decide what to pay for upfront and get what you need.

In addition to flat, fixed rates for the copies of medical records and digitized copies of the documents, you are paying for a service performed for one person, one time: the client with whom you are working. You don’t need to pay for someone in your office who is learning as they go and may be making mistakes because they are unfamiliar with the process, the terminology, and the outcome they want to achieve from the record search.

Sometimes you can save money by performing actions and duties with the staff you have in-house, but medical record retrieval is a field complicated enough that some people have made their careers on it. When you need this kind of complex documentation, it is worth paying for an external company with experience to handle it for you.

5. Specificity and Security are Key

You have a staff specialized in the tasks of maintaining a law office, not searching medical records. When you work with experts in medical record retrieval, you can count on the fact that they have done this many times, and they know what they are looking for at the providers’ facilities. They will get answers for you when you need them, without having to have long email exchanges about the request.

If you are really in a hurry, look for a company who offers the ability to search documents digitally as part of their package for medical record retrieval. You won’t have to look through paper records in your office, and you can use keywords to help you.

Using a service to gather the records for you will be very useful when you need to access the records. Your requests can be identified with a series of unique numbers and organized in one place. You can access these files with either a single login, or have permissions on multiple accounts so only the people who need access can get in.

Consider Medical Billing Analysts Today

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

How Medical Record Retrieval Services Help Attorneys?

Mon, 15 Mar 2021 09:07:00 GMT

When was the last time you performed a medical record search? Even if you specialize in injury cases, chances are you know a lot more about the specific rules, regulations, and laws that will get your client paid than the health care system that treated them after the incident.

When you need to present evidence of the treatment your client received, you will have to find the medical records around the time of the incident, but where do you start?

You could have an entry-level legal assistant track down each provider individually, from the original urgent care facility to the rehabilitative specialist your client saw when recovering. But why waste their time and your revenue when they are more suited to handling tasks related to your office and your case?

It may be beneficial for you to enlist the business of a Medical Record Retrieval Service . They have proven experience gathering the necessary data from providers and organizing it for use by your office when presenting a case. Read on for four reasons you should look at using a Medical Record Retrieval Service.

1. Customizable Searches

You don’t need your client’s entire medical history when you are searching for the records you need to complete their injury case. You only need to know the items related to the treatment of damage and conditions caused by the accident or attack, but how do you know what to ask for?

Unless you have someone skilled in Medical Record Retrieval services, you may get more than you bargained for, and you may end up with a large amount of paper bulk that you have to sort through that is otherwise taking up space in your office.

A Medical Record Retrieval Service will allow you to search for specific things in your client’s medical history so that you get the most precise information possible related to your case.

2. Medical Records Are Complicated

You hired people for specific tasks in your law office, not for medical records. A medical record retrieval service has relationships with the records departments of providers’ facilities to ensure that they get what they are asking for in a timely manner, without going back and forth.

The ability to search in digital records is an option offered by some medical record retrieval services, and can simplify the process of looking for specific events once the records are in your office.

Using a service that will gather the records for you will help you when you need to access the files, because your requests can be tagged with unique ID numbers, gathered into one place with a single login, or separated so that multiple people who all need authorization to view the records can do so through a secured area.

3. They Are the Experts

Because you are working with a company that handles these kinds of requests on a regular basis, they know exactly what they are looking for, and they will be able to deliver results in the timeframe you need.

Some services offer you the ability to track your request with status updates, but all of them should maintain communication with you throughout the process so you know where it stands.

The records you receive from some of these services will already be organized chronologically for you so that you know where to look for specific items that you need for your injury case, and don’t have to wade through the whole backlog of a client’s medical file in order to get to the dates of the incident you need information about, it will already be where you expect it to be.

4. Cost Savings from Outsourcing

When you use a medical record retrieval service, you know what you are paying for upfront. Each request and digital copy should have a posted fee from the medical record retrieval service you choose to use so that you understand what your money is going toward.

Not only do they have fixed rates for the medical records and access to the digital documents, but they are providing you a one-time service for the client you are requesting information about. You do not have to pay an hourly rate for someone working in your office who is inexperienced with the details of medical record searches to learn along the way and spend extra time because they go to the wrong place or do not follow up correctly with the records they need for your case.

You can save money in some cases by taking care of things in-house, but when you need to get information for an injury case, it is worth it to pay an external company with the experience necessary to get the job done quickly and efficiently.

Why you need Medical Billing Analysts

Furthermore, you need someone with the connections and expertise to handle retrieving medical records to be used in your case.

Medical Billing Analysts offers litigation support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represents both defendants and plaintiffs with regard to improper medical billing and coding.

Medical Coding – What is Ahead for 2020 and Beyond

Mon, 01 Mar 2021 11:53:00 GMT

Even before the pandemic hit in early 2020, there were changes made to the medical billing system. Fortunately, some of the codes that were implemented help with describing distance medicine. With temporary codes being finalized or canceled for Medicare and Medicaid, as well as how time is counted and billed, best practices change quickly.

Those aren’t the only changes the AMA made in 2019. Some of the decisions they made to change codes reversed previously approved decisions, and they will take effect as of January 2021. Are you prepared for what is ahead in the world of medical billing? Read ahead for some of the most important changes made to the current procedural terminology for 2020 and beyond.

Medicare and Medicaid Changes

The Centers for Medicare and Medicaid Services (CMS) have requested changes to the Medical Coding for a long time that will allow for greater flexibility in coding and access to care. The key changes here are some additional codes to describe time spent on outpatient visits managing chronic care.

Because the American Medical Association (AMA) must review the services and the codes for them, some of the proposed codes were withdrawn due to some concerns about administrative overhead inherent in incorporating temporary G codes GCCC1, GCCC3, and GCCC4 which pertain to the time intervals spent with a patient. They did, however, choose to finalize GCCC2, and is used for non-clinical staff time in the management of chronic care.

Evaluation and Management Changes

As of January 1, 2021, some of the codes that were finalized in 2019 were reversed. These decisions were made in 2020 but were not effective for a period of time to allow providers and their medical facilities to prepare for the change. These are specifically the 99211-99215 codes that allow for the accurate reporting of time spent with a patient.

Payers, including Medicare, must choose whether or not to adopt the changes to these codes. These are specific codes for outpatient time, and there have been no significant changes to observation codes or inpatient codes. Medical coding is consistently changing, however, so there may be changes to these codes in the future.

Current Procedural Terminology Changes

Current Procedural Terminology (abbreviated to CPT) is the list of accepted codes for explaining the services provided by a caregiver to a payer.

The American Medical Association issues the set of CPT codes , and the 2020 set was released in September of 2019. The new set of codes for 2020 contains a total of 394 changes. These changes can be more specifically described as 71 deletions, 75 revisions, and 248 new codes added to the list.

These changes mean that the field of medical billing is ever-evolving and it is important to make sure that the correct codes are being used at all times so that proper payment can be issued upon the completion of treatment.

Telehealth and Distance Medicine Changes

2020 and the beginning of a new global pandemic fundamentally changed the way that many providers had to approach healthcare. A significant number of visits now take place over video or phone calls rather than in face-to-face sessions.

In September of 2019, the AMA added a number of CPT codes that allowed for the use of novel digital tools for healthcare including patient portals. There are six new codes that help to report online and distance medicine visits such as patients who report their own blood pressure by checking it at home, and some that describe digital communications that are provided by a patient (and initiated by that patient) to a physician or other qualified health care provider, and also communications that are provided to a non-physician health care professional.

Some of these codes are, by necessity, used in conjunction with some of the codes for providing support for ongoing chronic care management.

Changes for Opioid and Substance Abuse Codes

The most significant change for the management of opioid and other substance abuse cases is that finalization was made for bundling certain treatments regarding ongoing care for these conditions. Namely, counseling services including psychotherapy, management, and care coordination.

G2086 through G2088 are used to describe office-based treatment and therapy and are dependent upon the length of treatment and the month in which the treatment occurs.

What is not included in these new bundles is Medication-Assisted Therapy, or, MAT for short. Any medication used in the treatment of these conditions would continue its separate billing under either Medicare part B or part D. Any medically necessary toxicology screening likewise would continue to be billed separately under the schedule of fees for clinical laboratory tests (CLFS).

Why You Need Medical Billing Analysts

Regardless of the extent of your medical claim, it is highly recommended to hire a medical billing and reimbursement expert to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

Medical Billing Analysts offers support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represent both defendants and plaintiffs with regard to improper medical billing and coding.

Medical Billers and Coders: An Integral Part of the Healthcare Industry

Mon, 22 Feb 2021 10:56:00 GMT

You went to the doctor, you gave them your insurance card, and a few weeks later got a bill in the mail for what insurance didn’t cover. What happened in the middle?

Medical billers and coders play a vital role in the system connecting health care providers, the patients they serve, and insurance companies that reimburse medical expenses.

One of the most crucial tasks performed by medical billers and coders is reading patient charts to determine medical history, including diagnoses and treatments given. Based on these charts, and a set of established medical codes, the medical biller and coder will transcribe patient history into an abbreviated format that is used by insurance companies to determine reimbursement.

The everyday function of a medical biller and coder includes properly coding any services, procedures, diagnoses, or treatments carried out by the practice. A medical biller and coder will also likely prepare and send invoices or claims for payment. In this article, we will discuss the steps in the medical billing process and the possible consequences if there are errors.

What is The Coding Step?

The standardized CPT and ICD codes are used by health care providers, hospitals, insurance companies to track and record the details of a patient’s visit and make sure that claims are processed properly. Each code has guidelines on how it can be used, and the penalty is steep for knowingly falsifying a code that will cause the insurance company to reimburse the facility at a higher rate than the service or treatment performed.

What is The Billing Step?

Medical billers and coders are sometimes combined in the same role. When they are not, the medical biller uses the shorthand from the medical coder and submits claims to the insurance company. The biller will then follow up with both the insurance company and the patients, making sure timely payments are made so that the medical practice receives compensation and the patient is billed appropriately.

After the Claim is Reported.

The information in the transcript of codes is submitted to the patient’s insurance company as a claim and the insurance company pays a certain amount to the healthcare provider based on the codes listed and what the patient’s plan covers.

After the insurance company pays their portion of the cost, the remaining amount is billed to the patient. Co-pays and deductibles the patient has paid are figured into the revised amount to pay. Accuracy is just as important in medical billing as in medical coding because it directly affects the amount the patient will pay, and there is ample opportunity for conflicts to arise from errors.

Medical coding and medical billing are two facets of an important checkpoint in the healthcare system to make sure that health services are being reported accurately, that information is given to the insurance company, and a true and correct final invoice is sent to the patient. Both jobs are very important to ensure that the health care facility is reimbursed correctly.

What Happens When There Are Mistakes?

The consequences of errors in medical billing can have far-reaching effects. When a code is not entered properly by the coder, it is passed on by the biller to the insurance company. As mentioned above, there are hefty consequences for knowingly using the wrong codes to overbill insurance, but what about other mistakes and oversights?

If your claims are part of ongoing litigation, you want to make sure that every piece of your treatment was billed properly. If you were overbilled and the settlement will only pay for the treatments you should have received, this can mean a lot of money out of pocket for you.

Not all medical billers and coders are familiar with the unique challenges inherent in analyzing injury claims or projecting future costs, and if this is a concern then you should make sure that a medical billing and coding company is involved to look over the bills and ensure everything is in place.

Medical billers and coders are not responsible for patient care, but a working knowledge of medical terminology and the ability to discuss the details of medical bills with carriers and patients is vital. In some circumstances, it is worthwhile to have a medical biller and coder who can prepare an expert witness report that can be used if the medical treatment was part of an injury or accident case and there are legal proceedings involved.

Why You Need Medical Billing Analysts as Your Medical Billing Company?

It is highly recommended that a medical billing company is used to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements, which is why Medical Billing Analysts is a perfect choice, with offices around the country.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in cases where healthcare costs are being argued is the topic of medical bills. Figuring out medical costs can be a difficult prospect, and having a medical billing and reimbursement expert to offer guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

The team of MBA professionals will review bills from the hospital, outpatient treatment, and therapy in order to determine the total costs of past medical expenses, and based on local CPT codes they can also perform a Cost Projection Analysis of ongoing costs. Through meticulous analysis, we can offer an estimate of how many medical costs will be in the future, to help justify the reasonable cost of services that assists in resolving the case.

You can reach Medical Billing Analysts by phone or email at 800-292-1919 or intake@medicalbillinganalysts.com . We’re ready to handle your medical billing needs, regardless if you need a single charge to be evaluated or if you are involved in litigation in a complex case, where injuries are just a part. Contact us today.

How to Find a Cost-effective Medical Billing Company?

Mon, 15 Feb 2021 14:00:00 GMT

Medical practices deal with billing every day. As part of the process of providing medical care, it is necessary to report treatments to insurance and make sure that all the services are billed appropriately.

It can be a challenge for practices to keep someone on staff who is trained in all the necessary areas of medical billing. In fact, many outsource this role to a third-party service.

If you are considering using a medical billing company to handle this service, you need to consider the level of support you will receive before you simply choose the least expensive option. There is a tradeoff between value and service, and you need to make sure that the company you choose is truthful in its offerings and will perform well when you need them.

Consider these five potential pitfalls before deciding to send your business overseas rather than trust a domestic medical billing company.

1. Dedicated Support

When you encounter issues with your medical billing, it is imperative to have a fast and reliable support from your vendor. Overseas medical billing companies will be operating in a different time zone, making it difficult for you to get the help you need when you need it. This leaves you inconvenienced by having to call at times irregular to you, or leaves you waiting on responses that may be lost because they are calling back when you cannot accept the call. Your best option is to have a medical billing company with an office in your time zone.

2. Support for Patients When Processing Statements

If you send your medical billing overseas, you may encounter issues when your patients are trying to deal with the medical billing company directly. Health is important to everyone, especially when it comes to a high cost of care. It can become an emotionally charged situation when a patient is dealing with a bill.

Thus, having someone they can understand, who also understands them is paramount to a smooth customer experience. Having adequate support, especially in a time of need such as an injury claim, is essential for building trust in a medical billing company.

3. Is Medical Coding A Service They Provide?

The cheapest medical billing company you can find may not offer you the support you really need. The world of medical billing and coding is changing constantly and having a vendor with the knowledge and experience to handle medical billing codes will save you headaches in the long run. That is true particularly when you make sure that codes are represented properly to the insurance companies. Even when providers do their own coding, it is best to have another party check to make sure the codes are correct, as it has a direct effect on reimbursements.

4. Experience, or Lack Thereof

When you think of the reasons why you are looking for a medical billing company, what comes to mind? Are you trying to ensure that all treatment items were billed appropriately for reimbursement of a claim or future cost projections on treatment?

While hiring an offshore company is attractive from a cost standpoint, it is entirely possible that they will not have the depth of experience necessary to handle billing challenges that arise, leaving you to spend more time and money than you wanted to in order to fix it. Investing a little more in a local company will save you the hassle of working through errors from inexperienced medical billing processors.

5. Security Practices and Compliance

The regulations around the handling of healthcare data are very strict, as well they should be. It is crucial that no one is able to intercept and collect any private and personal information about patients or vendors. Any breach of security in this regard is a serious blow to brand reputation and can be difficult to recover from in the eyes of prospective patients.

When you provide information to overseas companies for processing, it greatly increases the risk that this data will be exposed. It is of the utmost importance that you trust your medical billing and coding vendors and that you have properly investigated to ensure they are vetted. It is much easier to check on these characteristics with a domestic company as opposed to an offshore company.

Why You Need Medical Billing Analysts

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in cases where healthcare costs are being argued is the topic of medical bills. Figuring out medical costs can be a difficult prospect and having a medical billing and reimbursement expert to offer guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

4 Most Common Medical Billing Errors

Mon, 08 Feb 2021 15:38:00 GMT

Unfortunately, injuries and hospitalization come with the unwelcome prospect of medical bills, especially if there is a lawsuit accompanying the injury and it is necessary to argue for damages.

The healthcare field is comprised of many different moving pieces, all of which need to work together for treatment to happen, insurance to be billed, and documentation of care to be provided to support procedures. Codes are used by medical professionals to indicate to healthcare insurance companies the type of care that was provided to patients.

But what happens when something goes wrong? Everyone is human and we all make mistakes. So, what are the most common mistakes to watch out for?

The 4 most common medical billing errors are Upcoding, Unbundling , Erroneous charges, and Duplicate Charges, and each one of these 4 most common medical billing errors affects the overall billing in a different way. Let’s talk about each.

1. Upcoding

Upcoding happens when a code for a more expensive treatment than the one that was provided is reported to the insurance company. This can occur as an honest error, but there are hospitals and other providers who have been caught doing this deliberately. It is illegal, and it is a fraud.

Examples of upcoding can include a sedative treatment being billed as anesthesia, or a procedure that was carried out by a nurse or an assistant being billed as if it were performed by a more senior doctor.

A review of the codes in your medical bills will likely be necessary to determine what is fair and reasonable in a case where the injury is involved. One of the first things you should do is check to make sure that the statement of treatment that you receive on your Explanation of Benefits matches up with the care that you remember receiving.

2. Unbundling

Unbundling is another type of improper coding that is also referred to as “fragmentation.” Certain providers, particularly Medicare and Medicaid will reimburse procedures at a lower cost if they are typically performed together. One example of this is incisions and closures that are incidental to surgeries.

Fraudulent billing of these charges occurs when they are “unbundled” or when multiple codes are used to bill portions of a procedure separately. It is fraudulent because ordinarily, the procedures would be together, and the healthcare provider can charge a higher rate.

Unfortunately, unlike Upcoding, which can often be an error when someone enters a code for a procedure that is similar to the one that is performed, Unbundling is more likely to be a deliberate cheat of the system. It is an effort to inflate the cost of the care provided to patients, which in turn results in the provider receiving a larger payout from the insurance companies. Unbundling may be harder for the average person to see because he or she might not think to check if the incision and closure are listed as separate items.

3. Erroneous Billing

This happens when the wrong code is entered entirely and maybe the easiest for the patient to spot upon reviewing their Explanation of Benefits. One of the reasons that an Explanation of Benefits usually says “this is not a bill” is because it is a breakdown of the services offered so that the patient can review a description of their care.

This, along with the next of the 4 most common medical billing errors is highly likely to be an accident. There are so many codes in the medical system that entering a few numbers out of order can entirely change the type of service reported, and it does not necessarily point to some sort of fraud.

4. Duplicate Billing

Duplicate billing is exactly what it sounds like when the same code is entered more than once for the same treatment or procedure.

This may be more difficult if a patient is trying to look for it in their Explanation of Benefits because often the services listed are simply funneled under catch-all terms such as “Laboratory Services” or “Prescription Drugs” and without having a professional review the codes that were reported to insurance, it may be difficult to identify if more than one laboratory service was performed, or if the same one was a duplicate billing.

Duplicate billing is one of the 4 most common medical billing errors likely to simply be a mistake, where someone entered the same code twice without realizing it. Yet, it is still important to ensure an accurate representation of the treatment rendered so that the patient and the insurance company pay what is appropriate for the care.

If it is necessary to argue for damages regarding past medical bills or make a case for the cost of future medical care, then having a professional who is used to reviewing these codes can be critical to success.

Why You Need Medical Billing Analysts

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

The team of MBA professionals will review the hospital, medical, and therapy bills to determine the value of past medical expenses. Based on local CPT codes , they can also perform a Cost Projection Analysis of future costs. Through meticulous analysis, we can justify the reasonable cost of services which assists in resolving the case.

What to Look For When Hiring Medical Billing and Coding Expert?

Tue, 17 Apr 2018 10:20:00 GMT

Sifting through the technical information contained within medical billing statements is something that certified billers and coders are specifically trained to do. There are a lot of professionals who seem to be getting into the business of providing medical coding expertise, including doctors and nurses. While these professionals certainly have knowledge of the healthcare industry, they are not necessarily the best choice to evaluate the technical complexities of medical billing and coding , that’s where you’re much better off looking for someone specifically certified.

There are two national organizations to keep an eye out for when considering hiring a medical coding expert. AAPC and AHIMA. Both organizations provide programs for individuals to become certified billers and coders. The AAPC, or American Academy of Professional Coders, is one of the largest credentialing organizations and provides the CPC, or Certified Professional Coder, and CPB, certified professional biller designations, among many others.

The CPC certification validates proficiency in the correct application of CPT and ICD-10 codes. To obtain a CPC certification, a candidate must pass a 150-question exam covering questions regarding the correct usage of coding and billing guidelines and regulations. Passing this exam will allow the candidate to utilize the CPC-A designation, with the A signifying apprentice. It is not until the candidate has demonstrated a certain number of hours of coding work that they can have the apprentice designation removed and utilize just the CPC designation. Finally, once the candidate is CPC certified, they must submit 36 hours of continuing education units every two years to keep up with changes in coding and regulatory guidelines.

Certified Professional Billers have proven knowledge of how to submit claims in accordance with government regulations and private payer policies. To obtain this certification, the candidate must pass a 200-question exam covering questions regarding billing regulations, reimbursement, and collections, as well as billing and coding. Once certified, CPB’s must also submit continuing education credits to maintain credentialing.

The second organization, AHIMA, American Health Information Management Association, provides the CCS, Certified Coding Specialist certification, among others. CCS’ are skilled in classifying medical data from patient records to assign CPT and ICD-10 codes accordingly.

Beyond these credentials, you want to ensure that the medical billing expert you intend to hire demonstrates experience in billing and coding settings applicable to the type of bills typically included in personal injury cases. This would include billing and coding experience in orthopedic, physical, and/or occupational therapy, pain management as well as hospital settings. Having experience working in these areas gives the medical billing expert the tools they need to accurately evaluate a personal injury case.

Medical Billing Analysts (MBA) is a Nationwide Medical Billing Expert service with offices in NJ, NY, FL, TX, CT, GA, NV, and CA. To see how MBA can assist you in documenting the damages in your Personal Injury cases, consult www.medicalbillinganalysts.com or call 800-557-6141 for a proposal containing the experts’ professional qualifications, fee schedule, and sample Medical Expense Evaluation Report.

The Jargon of Medical Billing and Coding

Thu, 05 Apr 2018 10:14:00 GMT

There are many acronyms in the medical billing and coding world, including UCR, CPT, ICD, CMS 1500, and UB04. Understanding these acronyms will simplify your discussions with a medical billing expert and likely create a more efficient process overall. Medical billing and coding have a language all their own. If you and your medical billing expert can speak the same language, you’ll get to the finish line more quickly, and in a business that often charges by the hour, efficiency is key.

UCR, or usual, customary, and reasonable , is a term often utilized in the context of personal injury cases. The usual fee includes what the physician usually charges, or the submitted fee for a given service. The customary fee is one in the range of usual fees charged by providers of similar training and experience in a geographic region. A reasonable fee is one that meets both criteria or is justifiable considering the special circumstances of the case.

CPT codes , or Current Procedural Terminology codes, are published by the American Medical Association. They are used to report procedures, services, and supplies. Visually, you will recognize these as the five-digit numeric (sometimes alpha) codes. These are generally the codes that a medical billing expert is pricing out when looking at your case. There are literally thousands of CPT codes currently in use representing everything from brain surgery to repair of a broken toe. There are changes made to this code set and the rules applied to them on an annual basis and billers and coders also need to keep abreast of these changes.

The next important term to know is ICD9/10 or the International Classification of Diseases, ninth or tenth revision, clinical modification. These codes represent the diagnoses associated with the procedure or service a patient is receiving. The ICD code is used in conjunction with the CPT code.

To make it even more confusing, ICD9, or the 9TH revision, was used in the United States only up until October of 2016, when ICD10, or the 10th revision, was adopted. This is important for you only in that visually, ICD9 codes look different from ICD10 codes. ICD9 is a 3-5-character numeric code with ICD10 I a 3-7 character alphanumeric code. For billers and coders, though, the importance of learning the new code sets was imperative to the billing process. For example, an ICD-9 code for knee pain would be 719.46 which is nondescript. The ICD-10 code for the same diagnosis has more specificity. ICD 10 code M25.561 is for pain in the right knee, ICD-10 Code M25.562 is for pain in the left knee.

While a medical billing expert is reviewing a case, they will look at these diagnosis codes to determine whether the charge is related to the case. For example, if your case centers around a neck injury sustained in a car accident and you submit medical bills for doctor visits to treat a case of sinusitis, it is unlikely that your medical billing expert will include these charges in your claim for damages.

The final pair of acronyms pertain to the claim forms, or the forms doctors and hospitals use to bill insurance companies. There are two types, the CMS 1500 and the UB04. The CMS-1500 is the claim form used by doctors to the bill. Whereas the UB-04, Uniform Billing form, is the claim form used by hospitals, nursing facilities, and other inpatient providers. Both of these forms can be a wealth of information for a medical billing expert. There is so much more information on these billing forms than is contained on patient statements, which are often initially provided when records are requested.

What is Fair Health?

Thu, 29 Mar 2018 10:05:00 GMT

MBA has contracted with FAIR Health to assist in determining UCR for our Medical Expense Evaluations and Code & Cost Evaluations. Fair Health is a non-profit organization that collects charge data from private insurers and health plan administrators from across the country. They implement various statistical methodologies to compile the data and determine values at varying percentages, based on geographical location.

The central mission of FAIR Health is to promote transparency in the field of healthcare costs. The organization was established in 2009 as the result of a settlement of an investigation by NY State into the use of Ingenix’s database of reimbursement fees for out of network health services. The Ingenix database was often seen as biased given the fact that it was a subsidiary of United Healthcare, at the time the second-largest insurer in the nation. Therefore it was found that Ingenix may have had an incentive in setting rates low so insurance companies could underpay medical providers for out-of-network services.

More information regarding FAIR Health, its methodologies, data collection, validation, and security can be obtained at www.fairhealth.org.

Recent NJ Case Law

Fri, 23 Feb 2018 10:01:00 GMT

Recently in NJ there have been a couple of cases regarding medical expenses that have exceeded the limited Personal Injury Protection (PIP) coverage benefits and what fee schedule should be used for the medical bills in excess of the policy limits.

The first case is Viruet v. Maoine in Cumberland County in 2016. The question in this case was whether reimbursement for all plaintiff’s medical expenses, incurred because of their auto accident, be limited to the NJ MV PIP fee schedule and not just those expenses covered by the plaintiff’s $15,000 PIP policy. The plaintiff incurred medical expenses in excess of $56,000. The contention was not that plaintiff could seek economic compensation for the expenses incurred that were above the 15k policy, but rather that the expenses beyond the 15k should be limited to the NJ PIP fee schedule. This would have limited the dollar amount received by Plaintiff given the fact that this fee schedule generally pays at a much lower rate than UCR fee schedules. The court ruled in favor of the plaintiff indicating they were not prohibited from recovering the full amount of medical expenses incurred in excess of the 15k PIP policy.

The court came to this conclusion based on three points. First, the PIP carrier is not paying the medical expenses above the policy coverage limit, so the PIP fee schedule does not apply. Second, since the services provided are not covered by PIP, the medical provider is not limited to the PIP fee schedule when billing the patient and is free to bill for the full cost of the treatment, meaning that the plaintiff is then responsible for that full amount billed. Finally, due to the nature of the no-fault system, the plaintiff must go through the lengthy process of providing evidence, proving liability as well as reasonable and necessity of medical bills, their expenses won’t be instantly recovered. Even if they are successful at trial, collection of damages may be further delayed or limited based on the defendants’ insurance or financial situation. In this case, it was left to the jury to decide the fair and reasonable value of the $45,000 balance of the incurred medical expenses. This is a prime example of being ahead of the curve. Employing a certified medical biller/coder, in this case, would greatly support the actual value of the medical expenses and support the settlement amount.

More recently, in April 2017, we see Haines v. Taft argued in the Superior Court of New Jersey. The question, in this case, is whether the inadmissibility of evidence of losses, collectible under PIP coverage statute, precludes the recovery of medical expenses above those collectible or paid under a PIP policy, including medical expenses exceeding an elected PIP option. Specifically, plaintiffs, in this case, we’re seeking recovery of medical expenses in excess of their elected $15,000 PIP policy. Defendants argued that they could not be held liable for any expenses between $15,000 and $250,000, given that the “usual PIP limit in a standard policy” is $250,000. While it is true that the PIP benefit defaults to $250,000 if no option is chosen by an insured, there are indeed separate options, including $15k, $50k, $75k, etc.

Overall, the court ruled that those who choose PIP benefits for less than $250k take the risk of not having medical expenses immediately paid regardless of fault and need to pursue litigation to recover losses, in exchange for paying less for premiums. They ruled that in these cases, medical expenses between the PIP limit selected and the standard of $250,000 are admissible as uncompensated economic loss that can be recovered.

MBA is Co-Hosting a New Jersey CLE with OAS on Wednesday 1/17/18. Sign Up Now!

Wed, 10 Jan 2018 09:46:00 GMT

Medical Billing Analysts (MBA) and Occupational Assessment Services, Inc. (OAS are excited to host their CLE titled “Building the House of Damages in Cases Between 100K & 300K: Using a Vocational Expert/Life Care Planner & a Medical Billing Expert” on Wednesday, January 17.

The event will be held at the:

Location: Hilton Meadowlands

Address: 2 Meadowlands Plaza, East Rutherford, NJ 07073

Registration/Cocktail Hour: 5:00-6:00 pm

Seminar/Dinner: 6:00-9:00 pm

The CLE will include guest speakers:

Other highlights of the event will include:

If you have questions about this CLE seminar or OAS, please contact Verena Aibel at 973-365-4017 or email her: verenaaibel@oasinc.org .

MBA produces expert reports that support Usual, Customary, and Reasonable fee allowances for past medical bills and can testify, as expert witnesses, as to the actual fair and reasonable cost of medical care. We review many different types of cases on the plaintiff or defense side (for example hospital liens, PIP policy exhaustion, medical malpractice cases, mass tort, etc.).

In addition to our standard Medical Expense Evaluation Reports, we offer Code & Cost Reports. These reports assist attorneys by accurately projecting future medical exposure for Medicare Set Aside and Personal Injury cases in order to set appropriate reserves and determine the true value of a case.

Solid preparation of damages can help to strengthen a case once liability has been established. Engaging a medical billing and reimbursement expert to determine and testify to the reasonable value of medical services is highly recommended. Whether you are on the plaintiff or defense side, determining the cost of medical care is complicated and the guidance of an expert is critical to ensure you have a clear understanding of what is “fair and reasonable”.

For a complimentary case consultation or to find out more information, please contact MBA’s Senior Analyst, Jamie Anderson, CPB, CCS at 800-557-6141 . We’ll send a proposal containing the experts’ professional qualifications, fee schedule, and a sample report.

Medical Billing Analysts. Trusted Experts. Accurate Results.

Why You Need a Medical Billing and Reimbursement Expert? - MBA

Thu, 02 Feb 2017 09:19:00 GMT

Engaging a medical billing and reimbursement expert to determine and testify to the reasonable value of medical services, based on the provider’s location, is highly recommended.

Whether you are on the plaintiff or defense side, determining the cost of medical care can be complicated and the guidance of an expert is critical to ensure you have a clear understanding of what is “fair and reasonable.”

Fees: What is Usual, Customary & Reasonable?

UCR rates are the amount paid for a medical service, in a geographic area, based on what providers in the area usually charge for the same or similar medical service. UCR rates are an industry standard and accepted as appropriate reimbursement rates for medical services provided.

U – The Usual fee. This is a fee that is usually charged by the provider of a service or item.

C – The Customary fee. This is a fee that providers of the same specialty, in the same geographic area, charge for a service or item. It falls within a price range that other doctors in the area charge.

R – The Reasonable fee. This is for a service deemed necessary under the current conditions.

Upcoding and Unbundling Erroneous Charges

Wed, 01 Feb 2017 09:06:00 GMT

MBA will compile a comprehensive report by comparing submitted medical bills to a variety of benchmark fee schedules, market standard methodology, and computer databases. We will provide a line-by-line review of all medical bills submitted to verify their validity.

An expert Medical Biller will rigorously search for inconsistencies such as:

Our goal, at MBA , is to help your client get the highest settlement. We can testify to the legitimacy of all medical charges, incurred by the injured party.