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Archive for the ‘Healthcare Providers’ Category

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

Audits Are Increasing “Thanks” to New Healthcare Laws

Wednesday, May 25th, 2011

Hospitals and physicians are experiencing a great number of audits due to new reform laws that hope to reduce healthcare fraud, waste, and abuse. The most recognizable type of audit – RAC (Recovery Audit Contractors) are paid on a contingency basis – meaning they do not get paid unless they discover the hospital or the specific provider is billing incorrectly or other audit rules that may apply.

What you may not know is that the government has MULTIPLE types of audit programs out there looking into hospitals, home health agencies, individual providers, and DME (durable medical equipment) companies in order to decrease reimbursement for coding issues, lack of documentation, and inaccurate documentation among many other things.

What types of audits should you be prepared for?

  • MAC (Medicare Administrative Contractor)

o   Compliance with ADMINISTRATIVE COSTS

  • PSC (Program Safeguard Contractor)

o   Looking for FRAUD, WASTE, & ABUSE

  • ZPIC (Zone Program Integrity Contractors)

o   Looking for FRAUD, WASTE, & ABUSE

  • MEDIC (Medicare Drug Integrity Contractors)

o   Looking for FRAUD, WASTE, & ABUSE

  • RVC (Recovery Audit Validation Contractors)

o   Looking for OVERPAYMENTS

  • QIC (Qualified Independent Contractors)

o   Compliance with ADMINISTRATIVE COSTS

  • MIC (Medicaid Integrity Contractors)

o   Compliance with PROGRAM INTEGRITY

Why is this happening?

According to the “Summary of the 2008 Financial Report of the United States Government,” in 2008, Medicare hospital insurance benefits began to exceed program tax revenues.

The bottom line is there is not enough money. Private insurance companies are following suit – the application of contractor audit methods are being applied RIGHT now.

Remember, it is not about preparing for any particular “audit” program – it is about developing internal controls, effective mitigation strategies, and an effective response to any third party.

Thanks for reading!

Your healthcare resource – Rebecca Busch