How Can Working with a Medical Bill Advocate Benefit Your Law Firm?

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.

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 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.

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.