Lawyer Monthly - June 2022

Canyougiveus abrief overviewofwhat a medical billingexpert is required todo? The Medical Billing Expert: (1) Authenticates the services of the provider by auditing the medical record in relation to the charges billed. (2) Identifies the usual, customary and reasonable (UCR) charges per the American Medical Association definitions with application at the 75th-80th percentile. What are themost common situations that give rise tomedical billing lawsuits? Personal Injury cases are the most frequent because medical expenses are listed at charge rates “not within expected parameters” by the payer, be it a plaintiff or a defendant. Howare “usual, customary and reasonable” rates determined? The determination of UCR charges begins with validation of the service and correct coding of the service. It is then followed by an application of the 75th-80th percentile of geographically located charges. The AMA definition refers to the non- discounted fee schedule of a provider. The commercial/government payer definition of UCR is that of a calculated discounted rate. Such a figure is generally not submissible within states with a collateral source law prohibiting the use of payer information or write-offs. This discounted UCR is determined solely by the payer within their budgetary and contractual constraints. What constitutes aUCR chargeandwhat precisely defines thevalue for customary rate? The following discussion relates to the use of a non-discounted rate per the AMA policy (i.e. the “sticker price”). I. The American Medical Association policy states the conditions for which a charge is customary and reasonable and NOT a discounted rate. This definition is clearly an industry standard. II. The value of fees is most often determined by access to a reliable database with a range of percentiles in a specific geographic area for a specific service (per CPT, HCPCS or DRG codes). These figures fit The AMA definition, which states that “customary” refers to the range of usual fees charged in the same geographic area for the same services without a discount. To further define the UCR, the American Association of Nurse Life Care Planners has published that the range of customary fees “typically fall within the 75th to 80th percentile .” What should policyholdersdoafter receivinganunexpected bill formedical care that was not coveredby their insurance? It behooves the patient to fully understand 101 JUN 2022 | WWW.LAWYER-MONTHLY.COM EXPERT WITNESS and confirm their insurer’s coverage and non-coverage of services prior to scheduling care. Once a bill is received, ask to see an itemised statement of charges and compare them to what the patient actually received. For example, was the patient billed for three units of blood but only received one? Was there a “trauma team” charge of tens of thousands of dollars when the patient simply went home without any “trauma care” provided? There are also free patient websites available such as FairHealthConsumer. org that provide useful information about customary charges for services and procedures and insurance allowance amounts in the patient’s zip code. It includes the facility, surgeon and anesthesia charge data. The federal government has mandated that all hospitals provide a copy of their “chargemaster” or most common procedures on their websites. The No Surprises Act regarding emergency care requires individual states to provide ways of valuing the charges for the in-network and out-of-network scenarios of emergency care. Definitions and cooperative efforts are published by each state and each hospital. Certain specialties have seen a major surge in providers – and an accompanying surge in excess or upcoded fees. It behooves the patient to fully understand and confirm their insurer’s coverage and non-coverage of services prior to scheduling care.

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