Lawyer Monthly - June 2022

Howdoyouprepare to deliver evidence? First rule: The provider cannot bill for a service not provided. The provider cannot bill for a cost not incurred. The medical record must support the services provided in a correctly coded manner. Second rule: The charges are at or less than the 75th-80th percentile for the same service in the same geographic area. Once these two conditions are assessed, a summary report is presented with references to sources of information for evaluation of the services, correct coding and indication of the 75th-80th percentile as is customary. What are someof the most complex/interesting cases that youhave workedon? Outstanding cases fall into two categories – charges for services that were blatantly not rendered or documented and fees charged that simply are “off the chart” to a degree that any layperson would question their reasonableness. Some glaring examples of cases that I have reviewed and provided testimony: - A surgeon billed $400,000 (eight times UCR) for a surgery involving a musculoskeletal joint. The operative report clearly indicated that the provider did NOT actually perform that procedure! - A medium-level office visit was charged as a high-level office visit (upcoded and no other services provided) with a fee of $1,540. The 75th percentile charges were $213 or less. - A physician billed for a certain procedure performed in another facility (ambulatory surgery centre) where the patient received two bills – one for the physician and one for the facility. The physician is not entitled to the portion of the fee that includes “facility overhead”. The physician did not incur this expense. Such a difference resulted in a $12,000 fee reduced to a UCR fee of $3,500. - Hospital charges that were 21 times cost for spinal implants with NO overhead cost to the facility (i.e. $157,000 for implants that cost the facility $7,500). What doyouexpect tosee in the futureof medical billing litigation? Certain specialties have seen a major surge in providers – and an accompanying surge in excess or upcoded fees. It has been more than a decade since the AMA stated that its purpose for a UCR policy was to “prevent fee gouging by unscrupulous providers”. The issue is now more pertinent than ever, with an increase in demand of healthcare services and a simultaneous decrease in compensation by commercial and government payers. Criminal cases are now appearing for such abuses as upcoding and unbundling of charges. In summary, the rules to identifying medical billing abuses – either for fraud or excessive fees 102 WWW.LAWYER-MONTHLY.COM | JUN 2022 EXPERT WITNESS – are a battle fought in litigation scenarios in every state. There is clearly a need for the legal community and the patients who are assessed unreasonable fees to have a recourse regarding the issues of upcoding, medical record documentation errors and customary ranges of fees. Be sure to view this article on the Lawyer Monthly Website, where a number of useful sources are listed.

RkJQdWJsaXNoZXIy Mjk3Mzkz