Medical Billing Expert Witness
Medical Billing and expert witness must possess a thorough understanding of several factors and be comfortable providing oral and written testimony for depositions, expert reports and trial appearances in court. Establishing a baseline for usual customary and reasonable (UCR) costs for care starts with an evaluation of the clinical documentation and coding. An expert witness may use national charges adjusted for regional market medical billing as well as geographic adjustment factors used in medical billing for an expert witness to opine on market charges. The collateral source rules in various states may also be a factor.
- Inpatient procedures under the Inpatient Prospective Payment System (IPPS) for medical billing and medical coding expert witness
- Outpatient procedure under the Outpatient Prospective Payment System (OPPS) for medical billing expert witness and medical coding expert witness
- CPT codes (Current Procedural Terminology (c) American Medical Association for outpatient procedure expert witness
- CPT codes for physician coding expert witness and physician billing expert witness
- ICD-9 codes for diagnosis medical coding expert witness and inpatient procedure billing expert witness
- ICD-10 CM codes for diagnosis coding expert witness and ICD-10 PCS inpatient procedures
- DRG (diagnosis related groupings) used in the Inpatient Prospective Payment System (IPPS)
- Hierarchical condition codes (HCCs) used in risk adjustment for Medicare Advantage (Medicare Part C) or Accountable Care Organizations (ACOs)
- Relative value units (RVUs) in diagnostic imaging or the Outpatient Prospective Payment System (OPPS)
- Geographic analysis based on Geographic Adjustment Factors and wage Indeces
- Medical necessity as listed in Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)
- Prior authorizations
- Guidance from Medicare Administrative contractors (MACs)
A competent expert witness must be capable of using state and federal statutes, guidelines and industry best practices in these areas to support their opinions.