Medical Billing Expert Witness

The Medical Billing Expert Witness understand how to deal with complexity.  To clarify, the Expert must possess confidence in providing oral and written testimony for depositions, expert reports, and trial.  Depending on the facts being in litigation, this may include the value of medical care.  Usual customary and reasonable (UCR) costs for care starts with an evaluation of the clinical documentation and coding.

Furthermore, an expert witness may use national charges adjusted for regional market medical billing.  For example, the use of geographic adjustment factors (GAFs) to opine on market charges.  As a result, collateral source rules in various states may also be a factor.

Medical Billing Expert Witness Michael Arrigo
Michael Arrigo is a medical billing expert witness and medical coding expert witness.   Contact here. Federal and State judges and Arbitrators have affirmed Mr. Arrigo’s qualifications as an expert, in medical coding, damages, Medicare fraud, and electronic health records.  Recently interviewed on National Public Radio (NPR) as a medical billing expert.  Quoted in Kaiser Health News as a medical coding expert and expert on facility fees in surgical centers.  He is a published author and speaker.   Certified in documentation compliance, education includes Stanford Medical school in bioinformatics and Harvard Medical School in bioethics. Case retention by U.S. Department of Justice (DOJ). Retention by Defendants in complex alleged fraud cases.  He has led one of the largest Sarbanes Oxley Audits for a publicly traded company in the U.S.

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

On the other hand, in many jurisdictions, there are collateral source rules that apply in personal injury cases.  This means that the charge without considering insurance is the method to determine UCR of medical care.

Type of Litigation and Expert Scope

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.

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 Standard  by place of service and clinical context:

    1. CPT codes (Current Procedural Terminology is copyright American Medical Association). A CPT is for outpatient procedures and physician billing (see DRG codes).  The CPT codes for physician professional fees, and coding expert witness and physician billing expert
    2. CDT codes for dental care and procedures
    3. ICD-9 codes for diagnosis medical coding expert and inpatient procedure billing expert
    4. ICD-10 CM codes for diagnosis codes in all care settings, and ICD-10 PCS procedure codes for inpatient procedures

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 the professional fee or professional component (PC)  interpretation of a diagnostic image.  Consequently, the balance of the bill 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 billing expert witness should understand:

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 must be certified by the Centers for Medicare and Medicaid (CMS).  As a result, ASCs require higher capital investments to meet this certification.  As such, CMS certification entitles ASCs to charge facility fees for certain approved procedures.  Importantly, APCs contemplate a facility fee along with a bundle of procedures.

Home Health Care Episodic Grouping Codes

For example,

Home Health Agencies (HHAs) complete the Outcomes and Assessment Information Set.  This is often called an OASIS assessment.

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

As a result, the assessment groups the episode into one of 153 Home Health Resource Groups (HHRGs)

Other Factors in Medical Billing include RVUs, OPPS, Geographic Location and Wage Indices and Analytics

For example,

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 being able to articulate 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, the value of procedures may be different.  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 Local Coverage Determinations.   These are sometimes referred to as NCDs and LCDs. Guidance from Medicare Administrative Contractors (MACs) may be factors.

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 medical coding

Fee for Service vs. Capitated 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.  In the past two decades, business model innovations and value-based care experiments have created capitated risk models.  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 any higher cost procedures out of its own pocket.  Importantly, this is in contrast to FFS and seeking a higher reimbursement for the care of the individual patient from insurance.

Consequently, part of the underlying assumption is that with a large population, the capitated monthly cost covers the downside risk.  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.

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 models of payment

Case Law and Expert Scope of  Work, Opinions, and Testimony

For instance, a competent expert must be capable of understanding state and federal statutes, guidelines and industry best practices in these areas to support their 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, 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 expert testimony requested by retaining counsel is also important to consider.

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Michael Arrigo Interviewed by National Public Radio as Medical Billing Expert regarding high-cost medical billing

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