Medical Billing Analysis

Medical Billing Analysis

A medical-billing analysis is simultaneously the spine of the damages case and a future exhibit at deposition, mediation, and trial. A defective analysis (invented UCR figures, missed unbundling, undocumented charges treated as valid, pre-existing same-body-part treatment not flagged, lien holders not identified) either understates the case or hands opposing counsel impeachment material. This skill produces a memo where every charge is reconciled, every code is checked against the chart, every finding cites document/page/Bates, every red flag carries a stable taxonomy ID, and every jurisdictional assumption is surfaced for counsel.

The skill is billing-side: it does not value the case, draft the demand, build the full chronology, or resolve liens. It hands those off to sibling skills.

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Related skills

• medical-record-chronology — full date-ordered treatment narrative; consume it, do not rebuild
• medical-treatment-summary — narrative course of treatment
• damages-calculator — valuation, multipliers, present value; this skill feeds it the billing-side line items
• lien-resolution-summary — Medicare/Medicaid/ERISA/hospital liens; identify here, resolve there
• ime-report-analysis, expert-medical-record-omissions — defense-side rebuttal prep
• pi-demand-summary, demand-letter, mediation-statement — downstream consumers
• hipaa-release — verify authorization scope before requesting records

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Checkpoint A: Pre-Draft Intake (Mandatory)

Ask every time unless the user says "use defaults" or "just draft." Record gaps explicitly; do not silently proceed.

Required

1. Incident facts — date, mechanism, body parts claimed, jurisdiction, liability posture
2. HIPAA release scope — what records are authorized; whether 42 C.F.R. Part 2 SUD records are in scope
3. Medical records — every provider (ER, inpatient/operative, imaging, PT/OT/chiro, pain management, behavioral health, pharmacy, DME)
4. Itemized bills at CPT/HCPCS level — UB-04 for facilities, CMS-1500 for professionals; not totals
5. EOBs — for every claim (billed / allowed / paid / adjustment / patient responsibility)
6. Lien statements — Medicare (CMS conditional payment letter), Medicaid, ERISA plan, hospital/provider, workers' comp, VA/Tricare
7. Pre-incident records — same body parts, baseline function, medications

As applicable

8. Letters of protection — flag every LOP-billed line for RF-12 review
9. IME or peer-review reports
10. Life care plan — if future medicals at issue

Defaults if user does not respond (label every default in the output):

• Analyze chronologically; carry billed and paid as separate columns
• Flag treatment gaps > 30 days
• Apply three-prong causation screen per charge (temporality, consistency, medical necessity)
• Flag every jurisdictional rule [VERIFY]

Missing-material policy. Proceed with what's available. List missing categories in Section 4 (Open Items) of the output. Do not produce reasonableness or causation conclusions on a provider whose itemized bill is absent — name the gap and stop.

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Workflow

Step 1 — Build Document Inventory & Bates-Map

Classify each document, assign a short stable doc-label, record Bates range and OCR status. Use the categories listed in references/OUTPUT-TEMPLATE.md Section 5. The doc-label carries through every citation in the memo.

Step 2 — Reconcile Billing Arithmetic

For each provider, verify: billed = paid + contractual adjustments + patient responsibility + outstanding balance. Record the per-provider reconciliation row (Section 7 of the output). Any failure to reconcile is itself a flag — identify the underlying cause (RF-04 duplicate, RF-05 phantom, an unrecorded adjustment, or a data-entry error) and record it. Do not paper over a delta; show it.

Step 3 — Validate Codes (CPT / HCPCS / ICD-10)

Per charge, check that:

• The code is valid for the date of service (CPT/HCPCS year, ICD-10-CM specificity).
• The code descriptor matches what the chart documents (procedure verb, anatomy, components).
• The diagnosis on the claim supports the procedure billed.
• Modifiers (-25, -59, X-modifiers, -26, -TC, -50, -RT/-LT, -51, -22) are used correctly.

Detailed mechanics, modifier-misuse catalog, NCCI/MUE framing, and DRG considerations: see references/CODE-VALIDATION.md. Never assert a code-text mapping from memory; cite the AMA codebook or CMS file, or label [VERIFY: billing expert].

Step 4 — Apply Causation Screen (per charge)

Three prongs, all required, applied to every billed line item:

• Temporality — treatment began promptly for the complained-of body parts
• Consistency — complaints documented throughout the course of care
• Medical necessity — care relates to the diagnosis and the mechanism of injury

Failures get tagged "potentially contested — attorney review" in Section 7's Notes column and surface as red flags (RF-23 through RF-28 as applicable). The causation screen is the same screen used by damages-calculator Step 2 — keep terminology aligned.

Step 5 — Run Reasonableness Review

Produce a benchmark range, not a single "reasonable amount." Use FAIR Health, MPFS, state WC fee schedules, and the case's own EOB allowed amounts. Geographic adjustment (geozip/locality) matters. Letter-of-protection lines get extra scrutiny.

Methodology, source list, percentile presentation, billed-vs-paid integration, and "when to recommend a billing expert" thresholds: see references/REASONABLENESS-METHODOLOGY.md. Never quote a benchmark figure that was not actually retrieved; if no benchmark was run, say so and recommend a billing expert.

Step 6 — Flag Red Flags (taxonomy IDs)

Use the stable IDs in references/RED-FLAGS-CATALOG.md. Categories: billing integrity (RF-01–RF-10), reasonableness (RF-11–RF-14), referral patterns (RF-15–RF-17), documentation (RF-18–RF-22), causation (RF-23–RF-28), IME/peer-review (RF-29–RF-31), liens/collateral source (RF-32–RF-35).

Each row in Section 11 of the output: ID | Name | Detail | Source | Suggested Attorney Action | Severity (H/M/L). Sort H → M → L. If a finding doesn't match any ID, mark it [NEW PATTERN — review needed] rather than inventing a permanent ID.

Step 7 — Identify Collateral-Source / Lien Interfaces

Identify lien holders (Medicare, Medicaid, ERISA plan, hospital/provider, workers' comp, VA/Tricare), record amounts asserted and notice status, and hand off to lien-resolution-summary. Do not negotiate, reduce, or resolve. Surface the billed-vs-paid jurisdictional rule for counsel; do not pick the measure unilaterally.

Step 8 — Produce Final Report

Follow references/OUTPUT-TEMPLATE.md section by section. Run the Pre-Delivery Checks at the bottom of that file before declaring the draft complete. The privilege header, citation format ([doc-label, p. N, Bates XXXXXX]), and the [F]/[A]/[O] tagging convention are non-negotiable.

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Checkpoint B: Post-Draft Alignment (Mandatory)

After delivering the draft, ask:

1. Additional providers or itemized bills still outstanding?
2. Client explanation for any treatment gap > 30 days, or for pre-existing same-body-part care?
3. Billed-vs-paid measure for this jurisdiction — which does counsel want presented as primary?
4. Specific causation disputes (IME contrary opinions) requiring deeper analysis?

If no response: recommend obtaining the missing provider's itemized bills (highest-value gap) and flag the billed-vs-paid jurisdiction question as the next decision. Proceed with the draft as authorized.

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Quality Audit

• [ ] Every finding cites document, page, and Bates (or is explicitly labeled unbated and listed in Open Items)
• [ ] Per-provider billing arithmetic reconciled in Section 7; deltas shown, not hidden
• [ ] CPT/HCPCS codes validated against documentation; modifier use checked per references/CODE-VALIDATION.md
• [ ] ICD-10-CM diagnoses match billed procedures; specificity and 7th-character encounter type checked
• [ ] Causation screen applied to every charge; failures flagged with the appropriate RF-23–RF-28 ID
• [ ] Reasonableness benchmark source named (FAIR Health, MPFS, state WC, EOB allowed amounts) and tagged [VERIFY]
• [ ] Billed and paid carried as separate columns until counsel selects the primary measure
• [ ] LOP-billed line items individually tagged; RF-12 considered for each
• [ ] Red flags use stable IDs from references/RED-FLAGS-CATALOG.md, sorted H → M → L
• [ ] Pre-existing same-body-part treatment distinguished from incident-related; RF-26 surfaced if not addressed
• [ ] IME / peer-review opinions cataloged separately from treating physician findings
• [ ] Lien holders identified in Section 12 only; not resolved (handed to lien-resolution-summary)
• [ ] Jurisdictional rules flagged [VERIFY] (billed-vs-paid, hospital lien statute, statutory caps, No Surprises Act)
• [ ] Missing records listed in Section 4 (Open Items); no findings made on absent records
• [ ] No invented codes, FAIR Health percentiles, NCCI edit pairs, MPFS rates, verdict figures, or citations
• [ ] Privilege header present; Section 15 attorney-review boilerplate present verbatim

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Jurisdictional Flags

A short reference for the agent or paralegal to surface in Section 14. Not a substitute for counsel research. Every entry tagged [VERIFY].

• California — paid-only measure for past medical specials per Howell v. Hamilton Meats & Provisions, Inc., 52 Cal. 4th 541 (2011) [VERIFY current law]
• Collateral-source-rule jurisdictions (e.g., New York) — billed amounts may be admissible as evidence of value; collateral payments cannot be used to reduce [VERIFY current law in jurisdiction]
• Reasonable-value jurisdictions — present billed, paid, and a UCR benchmark band; let the fact-finder decide [VERIFY current law]
• Medicare Secondary Payer — 42 U.S.C. § 1395y(b); Section 111 reporting; CMS conditional payment letter required before settlement when patient is a Medicare beneficiary [VERIFY current CMS process]
• ERISA plan reimbursement — US Airways, Inc. v. McCutchen, 569 U.S. 88 (2013); FMC Corp. v. Holliday, 498 U.S. 52 (1990); made-whole and common-fund doctrines generally do not apply against self-funded ERISA plans [VERIFY plan language]
• Hospital lien statutes — many states cap or reduce; cite the specific state statute and check perfection requirements [VERIFY statute]
• No Surprises Act (federal, 2022 effective) — balance-billing protections for emergency services and out-of-network providers at in-network facilities [VERIFY current regs]
• Letter of protection admissibility — many jurisdictions allow impeachment on referral source, factoring, and collection patterns; some recent appellate developments [VERIFY current law in jurisdiction]
• Per diem / multiplier limits and statutory damages caps — vary by state and case type [VERIFY] (consult damages-calculator)

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Anti-Hallucination Rules

• Never invent CPT/HCPCS/ICD-10 codes, modifier meanings, or NCCI edit pairs
• Never quote a FAIR Health percentile, MPFS rate, or hospital posted price not actually retrieved (cite URL/file/date or label "benchmark not obtained")
• Never quote a causation statement that is not in the cited record
• Tag every legal citation [VERIFY] unless it appears verbatim in a sibling skill in this repo
• Distinguish fact ([F]), assumption ([A]), and opinion ([O]) in Sections 9–11 of the output

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What This Skill Does NOT Do

• Does not value the case (use damages-calculator)
• Does not resolve, negotiate, or satisfy liens (use lien-resolution-summary)
• Does not produce expert testimony — billing experts (CPC/CCS/CPMA) and medical experts are required for admissibility on contested issues
• Does not opine on ultimate legal conclusions (liability, damages amount, causation in law)
• Does not draft the demand letter, mediation statement, or trial exhibit list (use the named sibling skills)
• Does not replace attorney review of the final memo

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Attorney Review Required

This skill produces attorney work product. The memo derives entirely from documentation listed in its Section 2 and assumptions stated in its Section 3. Jurisdictional rules flagged [VERIFY] must be confirmed by counsel before reliance. No output of this skill may be sent outside the legal team without attorney review and approval.