Medical Billing Expert Witness California
Medical billing expert witness California requires rendering opinions on the Usual Customary and Reasonable cost of care. I receive questions on the difference between different types of care, codes, and billing and the role of various entities in healthcare revenue cycle management and claims management. It is essential to consider
inpatient and outpatient payment rules, federal and state statutes, and industry best practices and guidelines. The privacy and security of patient records being evaluated as prescribed under the HITECH Act or HIPAA must include safeguards, policies, and procedures to ensure the privacy and security of protected health information (PHI). Medical billing expert witness work also requires a data-driven approach.
Importantly, in personal injury cases where damages are being litigated and those damages include medical bills, many states have a “Collateral Source Rule.” According to a recent Mondaq newsletter, California has no cap on punitive or compensatory damages, and the collateral source rule applies. Medical billing expert witnesses in California may need to work with counsel and understand various case law based on the facts in the case. See Howell v. Hamilton Meats & Provisions, Inc., 257 P.3d 1130 (Cal. 2011). Click here for a more detailed discussion of Howell v. Hamilton Meats and California rulings.
Also, the timing of expenditures in relation to inpatient care may be necessary. Diagnosis codes, including ICD-9 and ICD-10 CM as well as procedure codes, ICD-9 and ICD-10 PCS, as well as outpatient procedures using the AMA standard Current Procedural Terminology (CPT®) HCPCS codes may be factors. Inpatient stays may require reviewing Diagnosis Related Groupings (DRGs) using the IPPS (inpatient prospective payment system). Outpatient Prospective Payment System (OPPS) or Ambulatory Procedure Codes (APCs) may apply in an Ambulatory Surgery Center (ASC). Additionally, payments via various payors, whether private insurance, Medicare, and Medicaid via the Centers for Medicare and Medicaid, may be factors. Medical codes are determined by coders who rely on physician or physician assistant diagnoses and prescribed procedures. Additionally, diagnostic imaging, pharmaceuticals, and durable medical equipment costs (DME) may be factors.
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Clinical documentation review, medical coding including CPT, HCPCS and modifiers, ambulatory surgical centers and DRG validation, review of clinical policies, and medical necessity; in personal injury cases, we opine on customary charges without considering insurance. In payer-provider disputes, provide expert testimony regarding fee schedules or percent of billed charges if relevant, as well as Usual Customary and Reasonable charges (UCR).
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