Medical Billing Expert Witness in

Finding the right medical billing expert witness requires care and diligence.  Once you have found a potential expert witness, ensure that you are assessing these factors:

1. The Medical Billing Expert Witness understands how Standards are used. Standards create healthcare claims at a specific economic value. Depending on the jurisdiction and legal standard, a valuation can be based on a medical bill compared to Usual, Customary, and Reasonable (UCR) charges in the community in personal injury and medical malpractice cases or what a provider accepts as payment in full.
2. A medical coding expert witness understands how Standards apply to different types of medical care using different codes.
3. To clarify, the Expert must be confident in providing oral and written testimony. Expert reports, depositions, and trials require different skills. Depending on the facts of the litigation, this may include the value of medical care.
4. If applicable, ensure that the expert witness candidate you found has a solid methodology.  The methodology regarding Usual customary and reasonable (UCR) costs is important.  This starts with an evaluation of the clinical documentation and coding.

Finding a Medical Billing Expert Witness

Furthermore, I recommend finding an expert witness who can discuss national and medical billing charges in the community.   For example, using geographic adjustment factors (GAFs) to opine on market charges.  As a result, collateral source rules in various states may also be a factor.

Usual Customary and Reasonable (UCR) charge rates for medical billing and market definitions.

On the other hand, in many jurisdictions, collateral source rules apply in personal injury cases. This means charges without considering insurance. If insurance coverage is a factor, the patient diagnosis and prior authorization may be a component of the medical billing expert’s work. Different damages modalities apply in different types of cases and jurisdictions.

Type of Litigation and Expert Scope – Find a Versatile Expert Witness in Medical Billing

That is to say, if requested by counsel and allowed by the Court, experts may consider other factors.  These may vary and depend upon the jurisdiction and type of case.   To elaborate, types of case types include personal injury, malpractice, payor provider dispute, provider billing company dispute, fraud, etc. It may be necessary to either consider insurance payments or maximum out-of-pocket (OOPM) costs to a plaintiff.  A medical cost expert understands various modalities of care and places of service.  Also, a medical cost expert witness should be able to discuss differences between inpatient hospital and outpatient billing.

Selected Types of Medical Billing Codes

In addition, a competent medical billing expert witness should have a strong understanding of medical coding.  Furthermore, medical coding expert witness comprehends  each of the Industry Standards by place of service and clinical context:

1. 1. CPT codes (Current Procedural Terminology is copyrighted by the American Medical Association). A CPT code is for outpatient procedures and physician billing (see DRG codes).  The CPT codes for physician professional fees.  Coding expert witness and physician billing experts understand how to evaluate them.
   2. Medical billing code modifiers
   3. HCPCS codes used for various medications, some injections, home health services and medical devices.
   4. CDT codes for dental care and procedures
   5. ICD-9 codes for diagnosis medical coding expert and inpatient procedure billing expert
   6. ICD-10 CM codes for diagnosis codes in all care settings, and ICD-10 PCS procedure codes for inpatient procedures
   7. Diagnosis Relating Groupings (DRGs) used for hospital inpatient stays

Modifiers and Place of Service Codes

For example,

1. Use of Modifiers with CPT codes.  For example, a medical coding expert should understand that a modifier may indicate a diagnostic image’s professional fee or professional component (PC) interpretation.  Consequently, the bill’s balance is then the technical fee or technical component (TC) and does not include this modifier.   Global fees include both PC and TC.  Global billing may or may not apply.
2. Place of service (POS) codes which indicate the care setting such as physician office, Ambulatory Surgery Center, hospital, lab, etc.

Selected Bundled, Packaged, and Episodic Codes for Inpatient Hospitals and Outpatient Ambulatory Surgery Centers

For example, a medical coding expert witness should understand:

The use of DRG codes (diagnosis-related groupings) in the Inpatient Prospective Payment System (IPPS) applies in hospital stays beyond 24 hours.  The hospital facility bills DRGs, the physician’s bill uses CPT codes.

APC (ambulatory procedure codes) apply in bundling services into packages.  Importantly, Ambulatory Surgery Centers (ASCs) use APCs.  ASCs are CMS certified facilities authorized to perform certain surgical lower risk non-hospital procedures.  ASCs certified by the Centers for Medicare and Medicaid (CMS) require higher capital investments to meet this certification.  As such, CMS certification entitles ASCs to charge facility fees.  Fees may only be charged for certain approved procedures.  Importantly, APCs contemplate a facility fee along with a bundle of procedures. It is essential for medical billing analysis to evaluate revenue codes.  It’s also important to find duplicate facility fees.

Dialysis Episodic Billing using the ESRD Prospective Payment System (PPS).

Even when insurance is not considered, the charges and methods for bundling medical services with medications follow a customary pattern.

HHAs use OASIS assessments (Outcome and Assessment Information Set) to evaluate patients’ episodic eligibility for home health care.

Relative value units (RVUs) in diagnostic imaging or the Outpatient Prospective Payment System (OPPS)

Geographic charge variation based on Geographic Adjustment Factors and wage Indices

Damages Analysis and Medical Billing

Qualified medical billing experts may perform damages analysis. This requires understanding error rates and sample sizes, as well as articulating methods to use computer and software data analytics and methodologies.  This may include data normalization to standardize data from various sources into meaningful summaries.

Medically Necessary Care and Insurance Factors

As a result, when insurance is considered, procedures’ value may differ.  This may apply in commercial health insurance or  Medicare fraud cases.  Additionally, it may apply in disputes between payors and providers in damages analysis.

Consequently, Medical necessity may be a factor. To clarify, this can include Medicare National Coverage Determinations and Local Coverage Determinations, which are sometimes referred to as NCDs and LCDs. Guidance from Medicare Administrative Contractors (MACs) may also be a factor.

In addition, health care claims processes impact billing when insurance is considered.  Explanation of Benefits explains the difference between medical billing and covered services. EOBs may have adjustments codes that are useful.  To elaborate, Adjustment Codes may provide insight into health insurance policies and coverage determinations.

Furthermore, inpatient procedures under the Inpatient Prospective Payment System (IPPS) for medical billing and medical coding expert 

An Outpatient procedure under the Outpatient Prospective Payment System (OPPS) for medical billing and as a component of understanding for the medical coding expert witness.

Fee for Service vs. Capitation Models

Historically, a large percentage of medical care was compensated based on a fee for the service provided.  This is commonly called fee-for-service (FFS) medicine.  Business model innovations and value-based care experiments have created capitated risk models in the past two decades.  To elaborate, capitation means that physicians are paid a set monthly fee to care for each patient.  The physician (or facility) takes the risk and pays for higher-cost procedures out of pocket.  Importantly, this is in contrast to FFS and seeking a higher reimbursement for the individual patient’s care from insurance.

Consequently, part of the underlying assumption is that the capitated monthly cost covers the downside risk with a large population.  This model is not perfect.  This is because of the unknown future cost for a single patient with higher acuity conditions (the ‘sicker’ patient) in catastrophic cases.  To elaborate, in this capitated model, a risk adjustment method sets the monthly payment based on the patient’s condition.

Furthermore, a flexible medical coding expert witness should understand risk adjustment coding. Capitated, Risk-Adjusted Models use HCCs or Hierarchical condition category codes. HCCs apply in a special type of managed Medicare called Medicare Advantage (or Medicare Part C). Furthermore, Accountable Care Organizations (ACOs) may use capitated payment models.

Medical Coding Expert Witness, Case Law and Expert Scope of  Work, Opinions, and Testimony

For instance, a competent medical cost expert must be capable of understanding state and federal statutes.  Moreover, guidelines and industry best practices knowledge is important.  All of these areas are used to support expert opinions.  In California for example, The California Court of Appeal, Third Appellate District (Sacramento), issued an opinion in Uspenskaya v. Meline (Oct. 28, 2015, C071647) ___ Cal.App.4th ___analyzing whether the amounts a medical provider accepts from a medical finance company are admissible as evidence of the reasonable value of the service. To elaborate, the Court of Appeal held that the trial court did not abuse its discretion when it excluded evidence regarding a third party’s payment to medical providers for a lien in the lawsuit.

To clarify, this brief discussion is not by any means an exhaustive list of case law in California.  Nor does it address Federal case law or other state laws or the U.S.  Several cases focus on insurance as a collateral source to evaluate the cost of care and when it applies.  Furthermore, some states use percentage factors.  The scope of medical coding expert testimony requested by retaining counsel is also important to consider.

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