Medical Business Associates, Inc. Patient Hotline: 877-MBA-UWIN (877-622-8946)
Website
Web
Twitter
Twitter
Mail
Mail
Training Institute
Training
We Understand How Information and Money Move In Healthcare
 
     

Archive for July, 2011

Submitting Bills into Evidence

Wednesday, July 20th, 2011

In Illinois in order to submit medical bills into evidence at trial, an opinion is typically required to show that the medical services and charges were usual, customary, and reasonable. An earlier case is often cited Arthur v. Catour, 216 Ill.2d 72 that “to introduce an unpaid bill into evidence, a party must establish that the bill is reasonable for the services of the nature provided.”

Citing a more recent Illinois case, the plaintiff (citing Betty Kunz v. Little Company of Mary Hospital and Health Care Centers, et al., Nos. 1-06-1707 & 1-06-1814) “can establish reasonableness by introducing the testimony of a person having knowledge of the services rendered and the usual and customary charges for such services.”

The skill sets required for this type of analysis include understanding the environment of the services rendered, in addition to healthcare reimbursement.  The method for how healthcare is paid for is complex and layered with components such as understanding ICD (diagnosis codes) and CPT codes (procedure codes). You also have to look at how these services are rendered in the provider environment.  The generation of a provider bill is a multi-layered process. If you have one party that does not stipulate to the bills, then it becomes important to have those bills reviewed by qualified medical auditors.

The following provide some helpful hints of the information you should request:

1.       Provider request list:

  • CMS-1500 claim form for all professional bills and their itemized statement
  • UB claim for all facility claims
  • Any ancillary service, like durable medical equipment or pharmacy charges – ask for an itemized statement
  • Please inform the provider that you are seeking all ICD and CPT codes associated with the services rendered

2.       Obtain relevant medical records representing services rendered.

3.       Have your medical audit specialist review the information and identify any anomalies or bills with insufficient information.

4.       If you hit road blocks such as “this information is only for insurance companies”, please remind the provider that billing information contains protected health information (PHI) and according to HIPAA, the patient is entitled to obtain their entire PHI.

5.       Finally with the right information you will be in a position to have an opinion generated on the bills associated with your case.

Send me a note if you get “stuck” or hit a “road block” in the process!

Thanks for reading!

Your healthcare resource – Rebecca Busch

Cutting Healthcare Costs through Patient Advocacy

Tuesday, July 12th, 2011

During a recent conversation with a colleague, she informed me how she has been responsible for taking care of her elderly mother, driving her to appointments, filling her prescriptions, etc. She mentioned that her mother’s previous doctor always ordered tests – looking at her bone density, mammograms, chest X-rays – the whole nine yards. Initially, this didn’t surprise me, her mother is 87 and has emphysema and osteoporosis – the doctor is just trying to keep her healthy. However, after my colleague enlightened me, I thought about the subject a little differently.

First of all, let’s look at the age. Her mother is 87. She has stated repeated that these tests hurt her (mammograms especially, and she has very sensitive skin that tears easily). Even if these tests were positive or showed some sort of abnormality, she would most likely elect not to have surgery, radiation, or other forms of treatment.  Her mother’s attitude, “I am 87, I want to live a pain free, non-complicated life. Going to the doctor every month isn’t fun for me, or my daughter who has to take work off in order to drive me.”

I mentioned previous doctor in the first paragraph because my colleague’s mother was so fed up with all these tests and appointments that she went to a new doctor. The new doctor was very candid. She said, “Yes, I can order these tests. Yes, I could see you once a month. However, you’re pretty healthy and these tests aren’t going to tell us anything that we don’t already know, or that we could fix.” Now, the doctor could have been reimbursed by Medicare and secondary insurance for these tests – the mother wouldn’t have had to “pay” out-of-pocket anything. But, in that sense, we all are paying for unnecessary tests and visits.

This is only part of the problem. Luckily my colleague and her mother were informed enough to understand that they can say, “No” to these unnecessary tests and procedures. Other individuals might be scared into participating. This is an instance were having a patient advocate on hand, informing the patient of his/her rights would be ideal. A second ear to listen to diagnoses and conditions, and a trained mind to realize that an elderly person who is sensitive might not want these tests because they hurt or the results won’t produce anything the person doesn’t already know.

The moral of this story is to speak up when communicating with your physician. If you find yourself wondering why your physician is ordering tests, consult with another physician. Patients can cut healthcare costs on the front end by being savvy consumers.

Thanks for reading!

Your healthcare resource – Rebecca Busch

To Be or Not to Be (a Whistle Blower) that Is the Question

Thursday, July 7th, 2011

A follow up blog to a post concerning a nurse who was jailed and fined for reporting a doctor… It looks like justice was served in the end.

An Unfair Complaint

A Texas nurse is waiting to stand trial. For what you might ask… Illegal prescription use? Theft? Wrongful death? How about none of the above? Anne Mitchell is facing trial because she is a whistle blower and the doctor in question protested to the sheriff in the small Texas town that he was being harassed and defamed for no reason.

Mitchell wrote an anonymous letter complaining about Dr. Arafiles practices and “mishaps” – including a failed skin graft performed without surgical privileges, suturing a rubber tip to a patient’s crushed finger for protection and a large affinity to herbal supplements which he sold as a side business – to the medical board.

This “anonymous” letter was brought to the attention of Dr. Arafiles who immediately filed a complaint to his friend the sheriff who then issued a search warrant to seize the nurse’s computer and found the letter.

Mitchell had worked for the hospital system for over 20 years. She is a much respected member of the nursing community. She loved her job and only wanted the best for patients. She was doing what every nurse should do – report wrongdoing and highly questionable (on numerous occasions) practices performed by Dr. Arafiles.

Mitchell was charged of misuse of official information, a third-degree felony punishable by prison time and was also fired from her job at the hospital.

A Just Outcome

A jury found Mitchell not guilty. Karma also reared her ugly head, with Dr. Arafiles, the sheriff, and a hospital administrator faced criminal charges in connection with the prosecution and with the firing of Mitchell. The defendants agreed to pay Mitchell and another nurse who was fired as well $375,000 a piece for the wrongful firing.

The state medical board also charged Dr. Arafiles with poor medical judgment, nontherapeutic prescribing, failure to maintain adequate records, overbilling, witness intimidation, and other violations.

Following Dr. Arafiles’ hearing, the board gave the doctor the choice of 2 remedial education programs for physicians along with 8 hours of continuing medication education in medical record-keeping and another 8 hours in evaluating and treating thyroid disease. He has also been put on probation for 4 years and fined $5,000.

Final Lesson

Putting whistle blowers in prison would seem to be a deterrent to those in the future that witness wrongdoing. While there are certainly those that “blow their whistle” in hopes to receiving a grand payday, there are also concerned individuals that do the right thing and report the wrongdoings and injustices they witness.

We have laws in place to protect whistle blowers from retaliation. These laws are necessary to protect individuals who do the right thing and are not afraid of being call “tattletales.”

The whole point of protecting whistle blowers is to give people an incentive to report. Without an incentive we can expect fraud, theft etc. to only increase in the healthcare system.

Thanks for reading!

Your healthcare resource – Rebecca Busch