Medical charts and billing records play a vital role in civil and criminal cases focusing on fraudulent billing by healthcare entities. While datasets can also be obtuse and extensive, they hold essential information regarding key legal issues in complex litigation. When experts analyze bills and medical records, a focal point is often medical necessity and whether medical record documentation supports providers’ bills. Here’s how experts bridge the gap between medicine and the law to:
- Evaluate medical necessity
- Translate the narrative detailed in medical bills and records
- Shed light on—or help defend against—potential medical billing issues in civil and federal (False Claims Act) actions
Interpreting Billing Codes for Medical Necessity
Research shows that doctors believe at least 20% of all medical care provided is unnecessary, and some experts say about 70% of medical records contain errors. When it’s time to decode medical billing and records to evaluate medical necessity, these questions must be answered:
- Do the medical bills and documentation accurately reflect the treatment provided?
- Was the treatment reasonable and necessary based on the patient’s condition and medical history?
When billing and coding experts answer these questions, they analyze documentation regarding several key issues, including (but not limited to) whether:
- The billed CPT (Current Procedural Terminology) codes concur with the treatment provided.
- The documentation requirements have been sufficiently satisfied.
- Less invasive treatments were attempted before more invasive options were undertaken.
- In cases involving repeated care, there is documentation of prior outcomes, and that documentation supports readministering the same care.
The following issues often manifest in civil litigation and whistleblower (False Claims Act) claims alleging fraudulent billing:
1. Upcoding
Does the diagnosis justify the care, or was the diagnosis inflated so the medical bills could be upcoded and inflated?
Inflated diagnoses could mean diagnosing a condition that is not present or overstating the severity of a condition that is present in order to justify additional testing, treatment, and billing that is not medically necessary.
Assessing the potential for upcoding involves a careful review of medical records and bills, as well as patients’ medical histories and provider billing policies.
2. Falsified medical records
Was any critical information on the medical records omitted or misrepresented to try to justify certain treatment, procedures, or medications? Were records revised when new information came to light?
Answering these questions requires a meticulous analysis of the timeline and details of diagnostic and therapeutic interventions. Out-of-order data, dubious information, and incomplete records are some of the red flags that may signal falsified medical records and questionable medical necessity.
3. Overtreatment
Did patients meet the criteria for the testing, care, or procedures provided? Were they unnecessarily provided inpatient care or were they prescribed unwarranted medications?
Distilling these matters demands a critical examination of medical record documentation for signs of excessive referrals, overexuberant diagnostic testing, and medically unnecessary prescriptions and treatments.
These are just some of the matters billing and coding experts can investigate when it’s time to evaluate medical necessity as part of complex litigation. Others, of course, can arise—and when they do, the support of an expert can be pivotal to uncovering, explaining, and/or defending against them.
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