Medical Bill Reviews
Dawn Cook has completed over 300 Medical Bill Reviews for plaintiff and defense attorneys. Medical Bill Reviews are also known as Reasonableness of Past Medical Bills, Past Medical Bill Reviews, Medical Audit, Utilization Audit, and Bill Review. The methodology used for Medical Bill Review reports is to review bills and medical records and research the usual, reasonable and customary (URC) charges based on this information.
We compare the bills to the medical records to validate that the care given was related to the accident or alleged medical malpractice.
We compare the bills to the medical records to ensure the codes are correct for the care documented. If the codes are not correct, we assign the appropriate code and explain. If there is no code on the bills, we research the most appropriate code and add this information to the tables.
We provide the usual, reasonable, and customary (URC) cost that the research reveals for the geographical area where the treatment or equipment is received.
We show what resources were used to determine these costs. For both defense and plaintiff counsel, a Medical Bill Review report is a concise assessment of the codes and costs and the relationship to the injury.
A past medical bill review is an evaluation of medical care provided in comparison to the medical billing. The medical bills are organized into easy to read tables and a review is performed to ensure bills are:
- coded correctly for the care that is documented
- verified related to the incident/injuries
- no inappropriate billing such as unbundled codes and upcoding
Cost research is done to provide the information that the law firm needs, samples are:
- Payments made for the bills
- Charges that would have been made in cases of the VA or HMO that don’t provide bills
- Medicare allowable amounts
- Medicaid allowable amounts
- Usual, reasonable and customary (URC) cost in the geographical area where the treatment or services are to be rendered.
After the bills have been audited, cost research can be performed to apply reasonable and customary pricing, utilizing:
- Current Procedural Terminology (CPT) codes for professional services (i.e. physician services, radiology, therapy). Costs found in sources such as Med Fees, National Fee Analyzer, Fair Health
- Healthcare Common Procedure Coding System (HCPCS) for items like supplies, ambulance services, DME. Costs found via phone, internet, Medicare or VA research
- Diagnosis Related Groups (DRG) for hospitalizations. Costs found through American Hospital Directory, VA tables, Medicare and Medicaid tables
Once the bills are totaled, they are compared to the cost research.
Bill reviews are useful to the plaintiff to prove that the bills were related to the incident, reasonable charges, and necessary medical treatment.
Bill reviews benefit defense by helping to determine if bills were not related to the incident in question, were excessive in cost or treatment.
All medical billing related to the incident/injuries should be provided along with corresponding medical records; any medical expert reports should also be available for review as this can assist with medical foundation when determining if care was related to the incident and was reasonable, necessary medical care.
Yes, some facilities or insurance companies don’t bill, for example, Veteran’s Affairs, Kaiser, HMO, and foreign countries. In these cases, medical records can be reviewed to determine the service code, level, and type and then cost research can be done to provide the URC for that service.