Integrated Medical Bill Review Risk Management

Integrated Medical Bill Review and Subrogation

Integrated medical bill review combines silos into one solution.  This article provides a summary of various strategies to determine the value of medical bills. Plaintiffs in personal injury litigation should determine the usual customary and reasonable value, as should defendants. Defendants may call these strategies cost containment. The plaintiffs seek to determine the maximum value. In either case, it is in the party’s best interest to determine a credible opinion as to the value of medical care and the cost of prescription pharmaceuticals.

When personal injury cases settle, health insurance companies may claim a portion of the settlement payment. The insurance company may have a “health care provider or hospital lien,” “Worker’s Compensation Lien,” or “Government Lien” when Medicare, Medicaid, or the Veteran’s Administration lien. The Centers for Medicare and Medicaid Liability Medicare Set Aside (LMSA – see the discussion regarding the Medicare Secondary Payer Act and MMSEA Section 111 below) may also be relevant. These subrogation interest rights to the lawsuit’s proceeds are asserted so that before the injured party payment, reimbursement is paid to the insurance company. When beneficiaries sign an insurance agreement, there is usually a contract that allows the insurance company to seek repayment from the beneficiary for medical bills from an at-fault third party. This agreement is called a right of subrogation.

Medical Bills and Liens

In general, Federal and State Standards provide for doctors, government agencies, surgical centers, diagnostic imaging centers, hospitals, and other medical providers to recover reimbursement from personal injury settlements for treatment rendered. A medical provider may file a “lien” against a claim by an injured plaintiff with the county recorder’s office. The health care provider thereby registers their right to collect unpaid medical bills. The party who files a lien seeks to ensure that a person, group, or business receives compensation for services or goods provided to someone else. Filing a lien may result in the medical provider’s name appearing on the settlement draft with the plaintiff. It is wise to have an accurate valuation of medical bills before a plaintiff settles with a defendant or insurance company.

Return on Investment for Integrated Medical Bill Review

Up to sixty percent (60%) of worker’s compensation costs are associated with medical bills. Therefore, if the amount of the medical bill is unreasonable, the party who may owe the medical bill can seek to demonstrate the reasonable value.

As a result, liability and no-fault insurers, worker’s compensation insurers, self-insured ERISA plans, and others may seek medical bill review services. If the medical bill review and subsequent negotiation fail to achieve a satisfactory result, litigation may be the next step. In litigation, expert witness testimony determines the Usual, Customary, and Reasonable (UCR) value of the medical services in litigation when parties cannot agree. 

Integrated Risk Management and Medical Bill Review

Finally, entities who are “Non-Group Health Plans” (NGHPs) may not be aware of their duty first to determine if their insured is also a Medicare beneficiary. If so, they may also be unaware of their responsibility to report Ongoing Medical Responsibility and Total Payment Obligation to Claimant. Failure to report could result in harsh Civil and Monetary Penalties (CMPs)  far above the medical bill’s original cost.

As a result, our firm provides best in class integration between medical bill review, Third Party Liability determination, Medicare Secondary Payer Act compliance, and litigation consulting.

Specialties

  • High Dollar complex hospital medical bills
  • Ambulatory surgical center facility fees
  • Pharmaceutical prescription drug medical bills, drug pricing
  • DMEPOS medical bill review (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies)
  • Clinical documentation reviews to detect errors, unbundling, non-medically necessary charges
  • Medical coding examination (CPT, HCPCS, ICD-10, DRG, Revenue Codes, modifiers, units, and other Standards)
  • Medical bill review (using national and community charges for collateral source rule cases and net payments in payer-provider disputes)
  • National correct coding initiative (NCCI) and “CCI” compliance reviews
  • Out-of-network medical bills
  • Hospital bills with revenue codes, physician CPT codes, DRGs, multi-specialty professional fees and surgeries
  • Future medical costs, life care plans
  • Full-spectrum from medical bill review to litigation consulting via consulting and testifying expert witness opinions in State and Federal jurisdictions 

Medical Bill Review Integrated with Risk Management Services 

  1. We provide Third-Party Liability analytics to identify self-insured ERISA plan leakage, thus reducing costs.
  2. Non-Group Health Plan (NGHP) Mandatory Insurer Reporting – We perform Medicare eligibility checks using industry-standard electronic data interchange (EDI) transactions. We provide unparalleled risk-management and compliance management services for liability, workers’ compensation, no-fault, state-funded, and self-insured plans. Medicare Secondary Payer Act penalties. We perform MMSEA Section 111 research and reporting to detect Primary Payer / Secondary Payer risk using analytics for Non-Group Health Plan Responsible Reporting Entity (RRE) for our self-insured, workers’ compensation, state-funded, liability, and no-fault clients who insure those who may also be covered by Medicare.

Private Payer, State Medicaid, Medicare, Worker’s Compensation, No-Fault Expertise, and Compliance

Our insurance coverage policy experts in workers’ compensation and auto medical bills in every state to ensure compliance with state requirements, as well as Medicare requirements, fee schedule changes, and jurisdictional complexities. Maintaining current, consistent, and accurate rules and databases are critical to our bill review solutions. Our community presence allows anticipated changes to be coordinated by our centralized data management department, ensuring timely updates to the medical bill review and preferred provider network management team.

Modern, Integrated Bill Review

We built our medical bill review service on a platform backed by our national reputation as experts in the field. As a market leader, we offer a modern, cloud-based medical bill review platform, and in-network and out of network national data visibility. We provide a complete medical bill savings solution for all in-network and out-of-network medical bills associated with health plan and non-group health plan (NGHP) workers’ compensation, no-fault, property, and casualty, and auto liability claims. Our solution reduces the total cost of medical bills through a combination of rules-based technology, medical and clinician expertise, insurance coverage determinations and medical policies negotiations, and in-network and out of network expertise. Our reliable, regionally adjusted rules engine can review bills by place of service, inpatient, outpatient, and medical specialty. We provide Usual Customary and Reasonable charge opinions for collateral source rule applications and usual customary and reasonable payment rules for payer-provider disputes in a platform backed by decades of business and healthcare experience. We provide accurate and consistent medical bill review with the ability to provide expert reports and affidavits for litigation ready opinions as needed to maximize savings and provide options.

Bill Review by Certified Professionals

Our complete bill review solution includes the detection of inflated charges due to unbundling and can re-price the charges based on the correct national Standards. Our U.S. Federal Judge certified experts in Usual Customary and Reasonable charges use geographic data in expert fee negotiations. The review process for medical bills should include several facets. These include:

  • Causation determination via independent medical evaluation, i.e., did the treatment relates to the injury sustained
  • Whether the billed treatment meets the standard of care for the injury.
  • Prior authorizations, if applicable(*)
  • State-mandated fee schedules, when applicable(*)
  • Proper documentation to support the medical coding of and billing

(*) Not applicable in collateral source rule personal injury cases

Coded Medical Bill Procedures and Structured Data for Efficient, Reliable Bill Review Analysis

Our electronic billing system efficiently captures paper and electronic form, accurately achieving UCR billed charges. We integrate with standard Electronic Health Records, EDI systems, claim systems, and other data sources as needed.

Professional Chart Audits as Part of Bill Review

Our medical bill review services include expert staff who compares bills to the medical records to determine inconsistencies between the services provided and the services billed. 

Business Rule-Based Utilization Review

Automated business rules automatically assess under/over utilization and identify patterns of waste and abuse against national data, regional trends, and payer policies. It is essential to group medical documentation, including surgeon’s notes and diagnostic images, if applicable with medical coding and medical billing. We structure the data for rule-based assessments. The rules assist with:

  1. Reviewing proposed care to determine the appropriateness of frequency, duration, and place of service. 
  2. Augment our team to detect and avoid unnecessary treatments, and costs. 
  3. Apply rules for workers’ compensation for a prospective, retrospective, and concurrent review.
  4. Unbundling, duplicate billing detection.
  5. Streamlines second opinions, peer reviews, pre-certifications, and independent medical evaluators (IMEs)

HIPAA Privacy Rule, HIPAA Security Rule, and HITECH Act Compliance Considerations

The HIPAA and HITECH Act Protected Health Information Safeguards. Our technology and team know HIPAA, and we adhere to the HIPAA Privacy Rule and the HIPAA Security Rule. Unlike other medical bill review companies, we do not allow unencrypted electronic Protected Health Information (ePHI) to be received or transmitted. All of our work on patient data is encrypted and reviewed by trained, HIPAA certified professionals.

Expert Negotiation of Medical Bills

We offer technology integrated with human oversight and judgment. We combine data, analytics, and exert negotiators. Our clinicians can evaluate whether the billed procedures were medically necessary. We are in a better position to negotiate bills because we have the experience and certified experts to support our opinions. We can also serve as rebuttal experts for life care plans in litigation consulting should the medical bill negotiation fail to reach a satisfactory resolution. 

Expert Witnesses are the Litigation Component after Unresolved Medical Bill Review Negotiations 

Nearly all personal injury action that goes to trial will need at least one expert witness. Personal injury cases require plaintiffs to present technical arguments (such as the cause of an injury, medically necessary medical charges to treat the injury, or the usual customary and reasonable charges for medical bills incurred to treat the injury). Similarly, if a defendant disagrees with the opinion of the plaintiff’s expert witness, rebuttal experts may also be retained by the defendant or the defendant’s law firm and or insurance company.  

After attorney’s fees, expert witness fees are likely to be the largest expense in a personal injury lawsuit. For example, an expert witness in medical billing usually charges an hourly rate to review the case, prepare an expert report, appear for a deposition, and to provide testimony to the jury and the court in a trial. In simple personal injury and medical malpractice cases, this can amount to several thousand dollars. In a complex case, it can be tens of thousands of dollars, especially if your case requires several expert witnesses.

In conclusion, an integrated medical bill review process is essential in determining the value of medical care.

Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. He leads a team that provides Cybersecurity best practices for healthcare clients, ICD-10 Consulting, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, Insurance Fraud, payor-provider disputes, and consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been quoted in the Wall Street Journal, New York Times, and National Public Radio.

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