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August 2012
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Useful link to Medicare and MSPRC billing and diagnostic codes for auditing conditional payment letters

I found this link with MSPRC's website and thought it might be helpful to some of you.  This link takes you to the PDF lists of all the Medicare diagnosis codes dating back to 2002.   http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html

You can download the pdf files and open them in Acrobat and then CTRL F search for the codes that show up on your conditional payment letters from Medicare.  This will help you sort out medical visits that have been "coded" for payment for non-related medical procedures and visits.
This makes it easier to find and eliminate appointments for pre-existing conditions.  You can also scan in a long conditional payment spread sheet, do a conversion to searchable text (OCR) and then use the search feature on that to find the billing codes.
Hope this is helpful to some of you.
Chris Nichols
www.NicholsTrialLaw.com
www.NicholsTrialLaw.com 1.800.906.5984

Can a hospital seek a medical lien if the bills were submitted to workers compensation in NC?

I received a question by email and it is a good one so I'm going to post the question and the answer:

Can a medical provider claim a  lien under NCGS 44-49  if the medical bills have been paid by the workers compensation carrier prior to injured worker pursuing a third part claim against a tortfeasor?

Worker was injured, workers comp. paid his medical bills at the local hospital.  A case was pursued against the negligent third party and we just received a lien notification letter from the hospital.

Can they do this?

My answer:

No.  A workers compensation (WC) medical payment is a "payment in full."  The hospital submitted to WC, WC paid what is the allowable expense and the hospital has to write off the remainder.  They don't get to double bill or bill for the unpaid portion.

I would write the hospital a letter asking them to set out in writing what what the total charges are, what they have been paid in the past, and what they are asking from your client now.  

 

Get that in writing.  
The follow up with a letter to the department that claimed the lien and make sure you copy one of the Medical Dcotors in charge with the following laws:
A medical provider’s reimbursement is limited to the maximum amount approved in the NCIC Medical Fee Schedule, unless the provider has contracted with the insurer for a different amount. If neither the fee schedule nor a contractual fee applies, the maximum reimbursement allowed is the usual, customary, and reasonable charge for the service.
N.C.G.S. §97‐26(c)
N.C.G.S. §97‐90(e) governs this issue and states:
“A health care provider shall not pursue a private claim against an employee for all or part of the costs of medical treatment provided to the employee by the provider unless the employee’s claim or the treatment is finally adjudicated not to be compensable or the employee fails to request a hearing after denial of liability by the employer.”
N.C.G.S. §97‐88.3(c) establishes penalties for medical providers who improperly pursue private claims against employees:
“A health care provider who knowingly charges or otherwise holds an employee financially responsible for the cost of any services provided for a compensable injury under this Article is guilty of a Class 1 misdemeanor.”
That's straight out of the North Carolina Medical Society guide:  http://www.ncmedsoc.org/non_members/project_sustain/workerscomp_faq.pdf
I'm thinking that when faced with criminal liability, the hospital will about face on this one.
And of course, if  the bill was never submitted to or paid by WC, then I think they can claim a lien.  Though if they breached their duty to submit to WC, then they may just be completely out of luck.
Don't forget that WC does have a lien for the medical bills they paid.
Chris Nichols
www.NicholsTrialLaw.com

 

www.NicholsTrialLaw.com 1.800.906.5984