Medical Bill Reviews
Dawn Cook has completed over 400 Past Medical Bill Reviews for plaintiff and defense attorneys. Medical Bill Reviews are also known as Reasonableness of Past Medical Bills, Medical Bill Reviews, Medical Audits, Utilization Audits, and Bill Reviews. The methodology used for Past Medical Bill Review reports is to review bills and medical records and research the usual, reasonable and customary (URC) charges based on this information.
The bills are compared to the medical records to ensure that the care given was reasonably related to the accident or incident.
The bills are compared to the medical records to ensure the codes are correct for the care documented. If the codes are incorrect, they are assigned the appropriate code with an explanation. The most appropriate code is added to the tables if there is no billing code.
Cost research is done to determine the usual, reasonable, and customary (URC) costs in the geographical area for the year the treatment, services, or supplies were provided.
For defense and plaintiff counsel, a Past Medical Bill Review report is a concise assessment of the codes and costs and the relationship to the injury.
Dawn's Publications on Past Medical Bill Reviews
Dawn's Presentations on Past Medical Bill Reviews
- “Life Care Planning and Past Medical Bill Analysis, a Primer for Legal Nurse Consultants.” American Association of Legal Nurse Consultants, Bay Area Chapter of Northern California, April 12, 2022, virtual meeting, USA.
- “Past Medical Bill Reviews for the Nurse Life Care Planner” American Association of Nurse Life Care Planners, Annual Conference, March 12, 2022. Virtual conference, USA.
- “The Five Most Common Problems with Past Medical Bills.” International Association of Rehabilitation Professionals, Annual Conference, November 13, 2021. Virtual conference, USA.
- “Pain Management Procedures and Medical Coding.” American Association of Nurse Life Care Planners, Fall Conference, November 4, 2021. Virtual conference, USA.
- “Testifying as an Expert in Medical Coding, Billing or Auditing.” HealthCon 2020, American Academy of Professional Coders, April 6, 2020. Virtual National Conference, USA.
- “Analyzing Past Medical Bills: Do you know what you need to know?” American Association of Legal Nurse Consultants, April 4, 2019. Louisville, Kentucky.
- “Adding Past Medical Bill Reviews to Your Practice: A Natural Addition to Life Care Planning.” International Association of Rehabilitation Professionals, October 27, 2018. Charlotte, North Carolina.
- “Medical Bill Reviews, a Primer for Law Offices.” Las Vegas Valley Paralegal Association, January 16, 2018. Las Vegas, Nevada.
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.