To submit medical bills into evidence at trial
in Illinois it is typically required to show that the medical services provided
and charges incurred were usual, customary, and reasonable. To demonstrate the reasonableness of the
provided services and the charges of those services it is often necessary to
introduce the testimony of a person with knowledge of both the medical necessity of the services
rendered and the understanding of
usual and customary charges for
those services.
Many
times the medical appropriateness of the services provided is introduced by the
medical providers themselves or by providers within the same discipline. These individuals are not always the best
choice to demonstrate the appropriateness of the billed charges.
This analysis necessitates
understanding the environment of the services rendered, in addition to healthcare
reimbursement practices and methodologies
Complex System
The
healthcare reimbursement system is complex with multiple layers culminating in
both the billed price and the price that is ultimately reimbursed. The process varies with each place of
service. A thorough understanding of the
ICD (diagnosis medical record or the medical bills is fraught with a number of
hurdles. A HIPPA compliant release of
information is the first tool. The next
step is identifying the individual within the facility or provider’s office
that has the authority to release the record and the bills. Within many facilities and large offices
these are two different individuals. A
few well-placed calls to the provider will disclose the contact name and number
and the process for requesting the information.
As
previously mentioned providers periodically change billing systems and
methods. You will be told the UB no
longer is available. To avoid this
inevitable response it is prudent to request the medical bills periodically
throughout a long treatment cycle or as soon as possible at the end of
treatment. A gentle reminder that UB must
be supplied to the insurance carrier or the workers compensation provider to
obtain payment for services may help to overcome a reluctant participant. It may not hurt to remind them that HIPPA
states the patient is entitled to obtain their entire PHI (protected health
information). Ultimately, a subpoena may need to be issued to obtain the
completed medical and billing records.
With proactive preparation and a qualified medical bill reviewer your
bills will find their way to trial.
Preparation…
When enlisting the assistance
of an individual to attest to the usual, customary and reasonableness of the
medical bills the following documents should be obtained from the providers:
- CMS-1500 claim form for all professional bills (sometimes referred to a HCFA - the previous name for the CMS-1500 claim form)
- UB claim for all facility claims (UB92 or UB04 are acceptable)
- A dental Claim form from all dental providers
- Obtain an itemized statement from any ancillary service (durable medical equipment, pharmacy, transportation service, or medical supply company)
- Inform the provider that you are seeking all the procedure codes associated with the services rendered
Next…
It is
necessity to obtain all corresponding medical records if it is determined that
the person who will testify to the reasonableness of the bills will also be the
individual responsible to attest to the appropriateness of the services
provided. The medical reviewer will then be able to identify if the services
provided are related to the injury of record, are appropriate to care for the
diagnosis/ diagnoses, are medically necessary, and are actually documented as
provided.
Hurdles and Hope
The
process of obtaining the necessary information for the medical reviewer to
adequately assess the medical record or the medical bills is fraught with a
number of hurdles. A HIPPA compliant
release of information is the first tool.
The next step is identifying the individual within the facility or
provider’s office that has the authority to release the record and the
bills. Within many facilities and large
offices these are two different individuals.
A few well-placed calls to the provider will disclose the contact name
and number and the process for requesting the information.
As
previously mentioned providers periodically change billing systems and
methods. You will be told the UB no
longer is available. To avoid this
inevitable response it is prudent to request the medical bills periodically
throughout a long treatment cycle or as soon as possible at the end of
treatment. A gentle reminder that UB must
be supplied to the insurance carrier or the workers compensation provider to
obtain payment for services may help to overcome a reluctant participant. It may not hurt to remind them that HIPPA
states the patient is entitled to obtain their entire PHI (protected health
information). Ultimately, a subpoena may need to be issued to obtain the
completed medical and billing records.
With proactive preparation and a qualified medical bill reviewer your
bills will find their way to trial. By Barbara King, BSRN, QMRP, CPC, MSCC
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