Medical bills or itemized statements are associated with care rendered to an individual by a physician, hospital or group practice for a specific illness or condition. These amounts relate to hospital admissions, office visits, therapy or surgeries. Additional costs may be incurred for rehabilitation, injections, prescription medication or orthopedic appliances. In personal injury or workers' compensation matters, medical expenses are tied to an actual event, e.g., motor vehicle accident, slip and fall or injury in the course of employment. In addition to proving damages, medical bills contain an abundance of other valuable information that may be particularly helpful to the legal team in the litigation of a case.
The task of requesting, organizing and summarizing medical records is regularly handled by a paralegal. However, a paralegal should also be cognizant of the importance of issuing separate requests (perhaps even to other entities) for the release of invoices. Medical billing is often handled by an outside company (sometimes even by an out-of-state agency) on behalf of a health care provider. Inquiries should include the full name of the patient, date of birth, dates of service, as well as account numbers or medical record numbers. Note that if a client was treated in an emergency room or admitted to a hospital, there could be multiple physicians from whom you will need to obtain records. These encompass independent charges for services such as consultations, review of diagnostic studies, etc.
Medical bills are acquired in a variety of ways including: receipt from clients; issuance of valid subpoenas; executed authorizations; and court order. Due to the overwhelming number of requests, many health care providers secure the services of an independent organization to process inquiries. Businesses such as Chart Swap or MRO allow third-party requestors to establish portal accounts to simplify submissions and responses. The use of an outside company results in time and expense savings for both the provider as well as the entity while maintaining confidentiality. It is essential to follow guidelines and procedures of a provider when directing inquiries for release of medical expenses. Be sure to adhere to any unique requirements, e.g., special authorizations or pre-payments. Although time consuming, it may be beneficial to retain a paper-based folder or electronic spreadsheet of practices, noting details such as contact information and prerequisites. This added step will certainly facilitate the administration of requests and subsequent inquiries.
A paralegal may also be charged with the task of assisting a client in the submission of medical expenses for payment. Therefore, it is imperative to immediately: determine medical payments coverage via declaration pages; ascertain any state/federal agencies (Medicaid, Veterans Administration, Medicare, etc.); and determine any and all personal health insurance coverage. Procure copies of the health insurance cards from a client (verify current insurance as well as the health insurance at the time of an incident). Thereafter, create a chart in order to track the status of bills. Analyze accounts for clerical errors, duplicate or excessive charges, improper medical codes and relatedness to an incident. Medical expenses should be submitted for payment on a timely basis and in accordance with provider or group guidelines. It is important to track any bill denials, reductions or rejections (via explanation of benefit forms). Denials or reductions must be discussed with the supervising attorney in connection with re-submission, reductions, dispute letters, coverage issues or to preserve future claims.
Aside from the discernible benefits of securing a breakdown of charges, e.g., submission of demands, calculating damages or review by medical experts, other segments of detailed billing statements contain valuable elements that can be extracted for use by the legal team in the investigative and discovery aspects of a case. Therefore, consideration should be given to subjects as follows:
On occasion, health care providers require individuals to pay co-payments or incur out-of-pocket expenses for particular procedures or office visits. Alternatively, a client could have a high deductible health insurance plan. In those instances, a client must meet a certain financial threshold before insurance will cover medical charges. These out-of-pocket expenses and deductibles must be tracked. Oftentimes a health care provider will retain a ledger to distinguish out-of-pocket totals. Items include fees for physical therapy sessions, prescription medication, etc. Similarly, remind clients to retain receipts or paperwork documenting out-of-pocket costs or deductibles in connection with recovering medical expenses and in consideration of potential resolution of an action.
Itemized statements contain dates upon which specific diagnostic studies were performed such as MRI or CT scans, as well as added procedures such as laboratory studies. This information is predominately helpful in assessing diagnosis as well as lodging a separate request for release of reports and films from appropriate locations. Radiology invoices will also identify the requesting physician.
Typically, itemized patient statements will categorize both primary as well as secondary insurance. This information is especially useful following exhaustion of first party medical benefits coverage and in connection with submission of subsequent medical charges. Moreover, the early identification of insurance will serve to alleviate undue stress and delay in proper notification to potential lienholders, such as the Department of Public Welfare (DPW).
Billing logs or explanation of benefit forms denote medical treatment, service dates and payments. This data allows billing entries to be aligned with corresponding office visits and procedures. Account activity may also be particularly helpful in deciphering illegible handwritten office notes (i.e., dates of service). This comparison also assists a paralegal to confirm incident date, gaps in treatment or highlight the need to secure missing records. The account activity also provides details regarding specific office locations (in cases where providers have multiple offices throughout the county) as well as diagnosis.
Ledgers will also offer additional insight into the identity of health care providers not initially identified medical records, including primary care physicians, attending physicians, treating facilities, home care or nurse practitioners. For example, a hospital billing statement often identifies a responding EMS agency (i.e., method of arrival), emergency room physician or perhaps even a primary care physician. In this way, a paralegal can contact those providers to secure fees which were not included in the initial hospital statement.
In certain circumstances, the state and federal government and private health insurance companies assert liens against any settlement for payment of medical sums. The right of subrogation is dependent upon statute as well as the language contained in a policy or contract. When securing medical bills, remember to also place appropriate entities on notice of any potential subrogation liens. Request complete policy and contract language for review by an attorney. Disputes may arise including improper coding, unrelated treatment, failure to comply with appropriate reductions and type of insurance available. These items, along with negotiation, compromises or payments, should be discussed directly with your supervising attorney. These areas regularly involve complicated legal questions as well as complex contract interpretation prior to agreeing to any discounts and reimbursements. Additionally, it may be necessary upon occasion to seek the services of a lien resolution expert to handle mass tort or complex cases.
Outstanding charges can certainly become problematic for clients. If no insurance is available, providers will forward unpaid or unresolved costs to collection agencies or credit bureaus. Communication is key. Encourage the client to forward copies of correspondence received from collection agencies or credit bureaus to the supervising attorney. It may be advantageous (with the approval of the supervising attorney) to contact the respective entities to advise that a claim is pending. At the same time, issue a request that unpaid sums be held in abeyance until resolution of the case. This "hold agreement" will alleviate repetitive phone calls (which may upset the client) while also preventing negative reporting to credit agencies. In specified situations, a paralegal or the legal team may serve as a liaison between the client and collection agency in formulating an appropriate payment plan to satisfy any debts. In some instances, the supervising attorney may contact the health care provider and/or group to discuss compromise or resolution of remaining amounts. Any conversations, arrangements or agreements must be in documented to ensure compliance and avoid misinterpretations.
Finally, a reminder to allow adequate response time to your request. Billing agencies, external organizations and/or larger hospitals handle hundreds if not thousands of requests. Be mindful that priority may be given to certain requests depending upon extenuating circumstances such as critical care or expert review. It is unacceptable to leave threatening messages or write derogatory comments on follow-up requests. While it is vital to document requests and be persistent in addressing unanswered inquiries, communicate in a professional manner. Many providers and companies record telephone calls and in all likelihood you could in theory work with the same individual or department again in connection with a future request. You certainly do not want a negative reputation in the workplace or within the health care industry. Therefore, it is imperative to be respectful and professional in order to uphold a high ethical standard.
Medical bills not only serve to assist in the valuation of a claim but also provide a paralegal with a plethora of facts to support the legal team in almost every phase of a case. The knowledge and ability of a paralegal to comply with procedures in the prompt and proper submission of medical bills, provide periodic updates on the status of billing ledgers and monitor liens can prove invaluable in the damages aspect of a case. Moreover, securing separate medical statements may also provide an opportunity to assist the legal team in identification of outstanding and/or improper charges as well as extract helpful information, such as the identity of subsequent health care providers and out-of-pocket costs in consideration of favorable resolution of claims.