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NurseValue News

Volume 1, Issue 1


Current Topics

Submitting Medical bills into Evidence—Illinois Collateral Source Rule

To submit medical bills into evidence at trial in Illinois it is typically required to show that the medical services provided and charges incurred were usual, customary, and reasonable. To demonstrate the reasonableness of the provided services and the charges of those services it is often necessary to introduce the testimony of a person with knowledge of both the medical necessity of the services rendered and the understanding of usual and customary charges for those services.

Many times the medical appropriateness of the services provided is introduced by the medical providers themselves or by providers within the same discipline. These individuals are not always the best choice to demonstrate the appropriateness of the billed charges.

This analysis necessitates understanding the environment of the services rendered, in addition to healthcare reimbursement practices and methodologies

Complex System

The healthcare reimbursement system is complex with multiple layers culminating in both the billed price and the price that is ultimately reimbursed. The process varies with each place of service. A thorough understanding of the ICD (diagnosis codes), CPT codes (procedure codes), NDC (national drug code), DRG (diagnostic related group used in hospital billing, and CDT (current dental terminology).

Each hospital has its own charge master (billing system) and updates it periodically by its own proprietary process. Hospitals prices vary from procedure to procedure, from time to time, and by location. With few exceptions, hospitals are not required to make their charge masters public. Other healthcare providers also update their billing systems periodically making it difficult to determine what is customary and usual for a service within a geographic location.


When enlisting the assistance of an individual to attest to the usual, customary and reasonableness of the medical bills the following documents should be obtained from the providers:

  • CMS-1500 claim form for all professional bills (sometimes referred to a HCFA - the previous name for the CMS-1500 claim form)

  • UB claim for all facility claims (UB92 or UB04 are acceptable)

  • A dental Claim form from all dental providers

  • Obtain an itemized statement from any ancillary service (durable medical equipment, pharmacy, transportation service, or medical supply company)

  • Inform the provider that you are seeking all the procedure codes associated with the services rendered


It is necessity to obtain all corresponding medical records if it is determined that the person who will testify to the reasonableness of the bills will also be the individual responsible to attest to the appropriateness of the services provided. The medical reviewer will then be able to identify if the services provided are related to the injury of record, are appropriate to care for the diagnosis/ diagnoses, are medically necessary, and are actually documented as provided.

Hurdles and Hope

The process of obtaining the necessary information for the medical reviewer to adequately assess the medicalrecord or the medical bills is fraught with a number of hurdles. A HIPPA compliant release of information is the first tool.The next step is identifying the individual within the facility or provider’s office that has the authority to release the record and the bills. Within many facilities and large offices these are two different individuals. A few well-placed calls to the provider will disclose the contact name and number and the process for requesting the information.

As previously mentioned providers periodically change billing systems and methods. You will be told the UB no longer is available. To avoid this inevitable response it is prudent to request the medical bills periodically throughout a long treatment cycle or as soon as possible at the end of treatment. A gentle reminder that UB must be supplied to the insurance carrier or the workers compensation provider to obtain payment for services may help to overcome a reluctant participant. It may not hurt to remind them that HIPPA states the patient is entitled to obtain their entire PHI (protected health information). Ultimately, a subpoena may need to be issued to obtain the completed medical and billing records. With proactive preparation and a qualified medical bill reviewer your bills will find their way to trial.

RTW On Monday?

Physician’s often return a patient to work on Monday, following their midweek appointment and release to return to work. Have you ever asked why? All people, even physicians are creatures of habit. The work week usually starts on Monday and that is the day the physician thinks about for return to work.

The question the nurse should pose is whether or not the return to work on Monday is for medical reasons. The nurse should ask if the medical condition is going to really change from the patient’s office visit on Wednesday.

The next time a physician says “Monday”, ask him to consider “tomorrow” or perhaps the day after tomorrow. Another avenue to explore is starting the patient to work on Thursday so that he/she can have a short work week to condition for the following full work week. An alternative would be to suggest that the patient start to work on a less than full time basis for two days.

Bilingual Nurse Advantage

Many times patients gravitate to a healthcare provider that speaks their language. This makes a lot of sense as it makes it less difficult it is to describe symptoms and feelings to someone that understands. The bilingual nurse does not replace the provider’s interpreting staff. They are invaluable in their own right.

There is a huge advantage for the patient with the opportunity to interact with a bilingual nurse, especially when they are involved in a complicated medical condition or a workers compensation case that has rules and regulations they must abide by over and beyond the medical treatment plan. When trying to communicate with a patient via a translator there is the tendency to forget to ask certain questions or you can miss the minute clues that may lead to a clearer understanding of the patient’s needs and concerns thus facilitating a good medical outcome. Often patients will express their concerns to a bilingual nurse that they would not feel comfortable asking through a translator. The relationship is built on mutual understanding of both the language and the culture.

A Thought for the Day

Wild geese always fly in a V formation and travel as a community. As each goose flaps its wings, it creates an 'up-lift' for the birds that follow.

People who share a common direction reach their destination more quickly and with less effort than those who travel alone. That's because they are traveling on the thrust of one another.
When a goose falls out of formation, it feels the drag and resistance of flying alone and promptly moves back into formation to take advantage of the lifting power of the bird immediately in front of it.

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