The Medical Billing E xpert

1. The Medical Billing Expert The Medical Billing Expert Med-Econ Inc.

2. Medical Education RN CRNA BS Biology and Education The Medical Billing Expert CODING CREDENTIALS CCS-P Certified Coding Specialist CURRENT EXPERIENCE President - Med-Econ Inc. 30 years Multi-Specialty Group Management Critical Mass Professional Societies AHIMA AIHC MGMA OSMA AAPMEDICINE AHAP AAPMANAGEMENT AHA AAPC Benchmark Databases Physician Fee Reference Guides MGMA Benchmark Data AHA Benchmark Data AHD Hospital Data HFMA Benchmarks Non-Profit Hospital Financial Reports Consultants RHIT MD-JAMA published CCS-P LPT CPA MBA, Hospital Controller The Medical Billing Expert Med-Econ Inc.

3. PROVIDER Claim or an invoice Payment PAYER Adjustment or write-off The Medical Billing Expert Med-Econ Inc.

4. Claim or an Invoice Providers CODING CREDENTIALS CCS-P Certified Coding Specialist • Consultants • RHIT • MD-JAMA • CCS-P • LPT • CPA • MBA, Hospital • Controller Medical Education RN CRNA BS Biology and Education Medical Billing Expert • Professional Societies • AHIMA AIHC • MGMA OSMA AAPM AHAP AAPMANAGEMENT AHA • AAPC • CURRENT EXPERIENCE • President - Med-Econ Inc. • 30 years Multi-Specialty • Group Management • Critical Mass • Benchmark Databases • Physician Fee Reference • Guides • MGMA Benchmark Data • AHA Benchmark Data • AHD Hospital Data • HFMA Benchmarks • Non-Profit Hospital • Financial Reports PAYERS VERIFY PAYMENT IS USUAL, CUSTOMARY AND REASONABLE Adjustments or write-offs The Medical Billing Expert Med-Econ Inc.

5. Physicians Hospitals Other Facilities Physical and other Therapists DME and Equipment Pharmaceuticals Laboratory Services Claim or an Invoice Providers CODING CREDENTIALS CCS-P Certified Coding Specialist • Consultants • RHIT • MD-JAMA • CCS-P • LPT • CPA • MBA, Hospital • Controller Medical Education RN CRNA BS Biology and Education Medical Billing Expert • Professional Societies • AHIMA AIHC • MGMA OSMA AAPM AHAP AAPMANAGEMENT AHA • AAPC • CURRENT EXPERIENCE • President - Med-Econ Inc. • 30 years Multi-Specialty • Group Management • Critical Mass • Benchmark Databases • Physician Fee Reference • Guides • MGMA Benchmark Data • AHA Benchmark Data • AHD Hospital Data • HFMA Benchmarks • Non-Profit Hospital • Financial Reports PAYERS VERIFY PAYMENT IS USUAL, CUSTOMARY AND REASONABLE Government (CMS, HMOs, BWC) Commercial carriers Patient/Guarantor LIABILITY INSURER Adjustments or write-offs The Medical Billing Expert Med-Econ Inc.

6. Physicians Hospitals Other Facilities Physical and other Therapists DME and Equipment Pharmaceuticals Claim or an Invoice COURT PROVIDERS CODING CREDENTIALS CCS-P Certified Coding Specialist • Consultants • RHIT • MD-JAMA • CCS-P • LPT • CPA • MBA, Hospital • Controller Medical Education RN CRNA BS Biology and Education Medical Billing Expert • Professional Societies • AHIMA AIHC • MGMA OSMA AAPM AHAP AAPMANAGEMENT AHA • AAPC PLAINTIFF • CURRENT EXPERIENCE • President - Med-Econ Inc. • 30 years Multi-Specialty • Group Management • Critical Mass • Benchmark Databases • Physician Fee Reference • Guides • MGMA Benchmark Data • AHA Benchmark Data • AHD Hospital Data • HFMA Benchmarks • Non-Profit Hospital • Financial Reports PAYER VERIFY PAYMENT IS USUAL, CUSTOMARY AND REASONABLE LIABILITY INSURER Adjustments or write-offs The Medical Billing Expert Med-Econ Inc.

7. Physicians Hospitals Other Facilities Physical and other Therapists DME and Equipment Pharmaceuticals Claim or an Invoice COURT Robinson vs. Bates Ruling Usual, Customary and Reasonable Providers Previous Payers PLAINTIFF PAYER LIABILITY INSURER Payment is Usual Customary and Reasonable The Medical Billing Expert Med-Econ Inc.

8. Physicians Hospitals Other Facilities Physical and other Therapists DME and Equipment Pharmaceuticals Claim or an Invoice Providers CODING CREDENTIALS CCS-P Certified Coding Specialist COURT Usual Customary and Reasonable Medical Education RN CRNA BS Biology and Education Medical Billing Expert • Professional Societies • AHIMA AIHC • MGMA OSMA AAPM AHAP AAPMANAGEMENT AHA • AAPC • Consultants • RHIT • MD-JAMA • CCS-P • LPT • CPA • MBA, Hospital • Controller • CURRENT EXPERIENCE • President - Med-Econ Inc. • 30 years Multi-Specialty • Group Management • Critical Mass • Benchmark Databases • Physician Fee Reference • Guides • MGMA Benchmark Data • AHA Benchmark Data • AHD Hospital Data • HFMA Benchmarks • Non-Profit Hospital • Financial Reports Payment is Usual, Customary and Reasonable PAYER LIABLITY INSURER PLAINTIFF The Medical Billing Expert Med-Econ Inc.

9. Physicians Hospitals Other Facilities Physical and other Therapists DME and Equipment Pharmaceuticals Claim or an Invoice Providers COURT ALONE or a less qualified individual determines USUAL CUSTOMARY AND REASONABLE PAYER LIABILITY INSURER Previous Payers PLAINTIFF PAYMENT IS USUAL CUSTOMARY AND REASONABLE???????? The Medical Billing Expert Med-Econ Inc.

10. Without the Medical Billing Expert informing the Court of the value of the services as Usual, Customary and Reasonable……… LIABILITY CARRIER $$$$$$$ Med-Econ Inc.

11. How can the Medical Billing Expert reduce this loss? LIABILITY CARRIER $$$$$$$ Med-Econ Inc.

12. PROVIDER Claim or an invoice Medical Billing Expert PAYER Payment The Medical Billing Expert Med-Econ Inc.

13. Who are the PROVIDERS of medical services? What did the do and what did they charge? Who are the PAYERS for the Medical Services and what did they pay and write-off? The Medical Billing Expert Med-Econ Inc.

14. Did they submit clean and correct claim or an Invoice??? PROVIDER Medical Billing Expert Did Payer make correct Adjustments, Write-offs and Payment? PAYER The Medical Billing Expert Med-Econ Inc.

15. What gives the Medical Billing Expert the gravitas to provide an opinion of the UC&R or Fair Market Value of medical services? Med-Econ Inc.

16. CREDENTIALS • MEDICAL EXPERIENCE • BILLING EXPERIENCE • CONSULTANTS • BENCHMARK DATA • Graduate Level Medical Background • Coding Licensure by reputable entity • Current responsibilities involving educating providers and holding payers accountable – IN THE GAME!!!! • Active membership in professional societies • Utilize specialized consultants • Utilize major and reliable sources of benchmark data Med-Econ Inc.

17. Rebecca A. Reier BS CRNA CCS-P MEDICAL Registered Nurse CRNA-Certified Registered Nurse Anesthetist BS Summa Cum Laude Biology Sciences and Education LICENSED CODER CCS-P Certified Coding Specialist-1997 Annual Licensure Exam AHIMA ACTIVE President of Med-Econ Inc.- Practice Management company providing Coding and Accts Receivable processing over 30 specialties PROFESSIONAL ORGANIZATIONS AHIMA AIHC MGMA OSMA AAPMEDICINE AHAP AAPMANAGEMENT AHA AAPC CONSULTANTS and Benchmark databases RHIT Physician’s Fee MD- JAMA publisher Ref Guides CCS-P MGMA data LPT AHA CPA AHD MBA, Hospital Controller Med-Econ Inc.

18. How does the Medical Billing Expert make the determination that medical bills, payments and adjustments represent a fair claim for reimbursement (fair market value or Usual, Customary and Reasonable)? Med-Econ Inc.

19. Tools of the Medical Billing Expert • Definitions • Rules • Documentation Med-Econ Inc.

20. Definitions • Expert • Fair • . • Fair Market Value. • Usual, Customary and Reasonable (UC&R) Med-Econ Inc.

21. Variation in Definitions Black’s Law Dictionary American Medical Association Usual, Customary and Reasonable (UCR) Usual The fee an individual physician usually charges for the service Customary A fee that is within the range of usual fees of physicians in similar service in similar geographic areas Reasonable A fee that is justifiable considering the special circumstances of the particular case in question without regard to payments that governmental or private plans have discounted Usual, Customary and Reasonable (UCR) UsualCustomary CustomaryUsual ReasonableFair, proper, just, moderate, suitable under the circumstances…not immoderate or excessive Med-Econ Inc.

22. WHY does such a conundrum exist? Med-Econ Inc.

23. There is no limit to what the “sticker price” of a service can be; only a limit to what the buyer will pay. That price is -Fair Market Value- -Usual, Customary and Reasonable- Med-Econ Inc.

24. Med-Econ Inc.

25. Tools of the Medical Billing Expert • Definitions • Rules • Documentation Med-Econ Inc.

26. RULES • WHO MAKES THE RULES? • Medicare and Medicaid (CMS) • Resource Based Relative Value Scale (RBRV) • National Correct Coding Initiative (NCCI) • American Medical Association • American Hospital Association • World Health Organization • Physician and Provider Specialty Societies • Various other government and commercial insurers Med-Econ Inc.

27. Tools of the Medical Billing Expert • Definitions • Rules • Documentation Med-Econ Inc.

28. DOCUMENTATION • The Medical Billing Expert evaluates the documentation of the care rendered with regard to: • Validation that the charges, payments and adjustments are accurate • Validation that evidence of compliance with applicable RULES regarding documentation and medical necessity is present – CODING CREDENTIALS NECESSARY. Med-Econ Inc.

29. What difference does this evaluation by a Medical Billing Expert make for the liability insurer? The accurate evaluation of the Fair Market Value or UC&R of a medical fee can vary from >100% of the fee to 0% of the fee. Sticker Price $1,000 UC&R Value range from $200 to $1,500 Med-Econ Inc.

30. DOS Procedure Charges Allowance UCR Adjustment per CCI and CPT for frequency 12/07/2009 Trigger Points (20533) $100 $100 $100 Trigger Points (20533) $100 n/a 0 -$100 Trigger Points (20533) $100 n/a 0 -$100 Trigger Points (20533) $100 n/a 0 -$100 Trigger Points (20533) $100 n/a 0 -$100 Trigger Points (20533) $100 n/a 0 -$100 Totals $600 $100 $100 -$500 Original Charges $600Sticker Price Adjustment for erroneous charges -$500 UCR allowed amount $100The amount the liability carrier pays is 17% of the original charge Med-Econ Inc.

31. DOS Procedure Charges Allowance average UCR Adjustment per CCI based on 50 percentile of charges in zip code and average reimbursement rates per Medicare 12/07/2009 Shoulder Arthroscopy 29827 $7,355 7355 1082 -$6273 29828 $6,836 6836 917 -$5919 29823 $6,177 3088 (CCI ½) 311 -$5866 Totals $20,368 $17,279 $2310 -$18,058 Original Charges $20,368Sticker Price Adjustment for erroneous charges -$18,058 UCR allowed amount $2,310The amount the liability carrier pays is 12% of the original charge Med-Econ Inc.

32. Example of Documentation issue”If you did not document it, you didn’t do it” Excellent documentation Poor and unacceptable - American Chiropractic Association states that documentation must be legible The charges for therapy not documented resulted in a 15% decrease in amount liability insurer paid Med-Econ Inc.

33. Example of Applying AMA Definition of Sticker Price vs. UCR The provider’s charges were found to be: Twice the average fee for their geographic area (Not Customary) There was no attempt to bill the patient’s carrier although they were contracted providers (not Reasonable) There was violation in the provider’s office policy in regard to indigent (below Government Poverty Scale) patients (not Usual, Customary or Reasonable). These findings reduced the claim from this single provider from $56,000 (STICKER PRICE) to $5,600 (UCR Price)– a 90% reduction. Med-Econ Inc.

34. Regarding Hospital charges Largest dollar amounts encountered Nationally hospitals expect to collect approximately 33% of their charges. Healthcare Financial Management Association “Trends in Hospital Revenue Cycle Management” Sept 9, 2011 Med-Econ Inc.

35. Bottom Line for a liability insurer In this example: Medical Billing Expert Charges Opinion of UCR/FMV Surgeon20,300 2,300 Pain Physician 600 100 Multi-Specialty 56,000 5,600 Chiropractor 4,800 3,984 Hospital 100,000 33,000 Total $181,700 $44,984 The fair market value of these services is about 25% of the charges in this case. The evaluation of medical charges by a Medical Billing Expert provides the data that protects the liability carrier from paying unreasonable sticker prices. This prevents the $$$$ from going down the little black hole. Med-Econ Inc.

36. Without the Medical Billing Expert informing the Court of the value of the services as Usual, Customary and Reasonable……… LIABILITY CARRIER $$$$$$$ Med-Econ Inc.

37. Once the medical charges, payments, adjustments have been evaluated as data within Definition, Rules and Documentation criteria, the Medical Billing Expert provides an opinion of the amount that is fair for the providers, the patient and the payers. The average fee for Medical Billing Expert Opinion is based on hourly rates depending on the complexity and amount of data that is required to be reviewed. Medical Billing Analysis Med-Econ Inc.

38. Physicians Hospitals Other Facilities Physical and other Therapist DME and Equipment Pharmaceuticals Claim or an Invoice Providers CODING CREDENTIALS CCS-P Certified Coding Specialist Medical Billing Expert • Consultants • RHIT • MD-JAMA • CCS-P • LPT • CPA • MBA, Hospital • Controller Definitions Rules Documentation Medical Education RN CRNA BS Biology and Education • Professional Societies • AHIMA AIHC • MGMA OSMA AAPM AHAP AAPMANAGEMENT AHA • AAPC COURT • CURRENT EXPERIENCE • President - Med-Econ Inc. • 30 years Multi-Specialty • Group Management • Critical Mass • Benchmark Databases • Physician Fee Reference • Guides • MGMA Benchmark Data • AHA Benchmark Data • AHD Hospital Data • HFMA Benchmarks • Non-Profit Hospital • Financial Reports Payers VERIFY PAYMENT IS USUAL, CUSTOMARY AND REASONABLE Government (CMS, HMOs, BWC) Commercial carriers Patient/Guarantor LIABILITY INSURER Adjustments or write-offs The Medical Billing Expert Med-Econ Inc.

39. In the end, this is about seeking FAIRNESS in a complicated healthcare market place. Fairness for the patient, the providers and the payers. Med-Econ Inc.

40. “Justice cannot be for one side alone, but must be for both.” Eleanor Roosevelt Med-Econ Inc.