Consultation and Audit Booking

Terms of Service

1. Nature of Services (Forensic Audit Scope)

A. Independent Analysis & Statutory Authority

Medical Bill Forensics LLC provides independent, third-party forensic analysis of medical billing documents based on federally mandated, medical billing and coding practices originating from the Health Insurance Portability and Accountability Act (HIPAA) – specifically HIPAA Title II (45 CFR 160 and 162) – and Section 1173 of the Social Security Act.

The U.S. Department of Health and Human Services (HHS) holds the statutory authority to adopt and mandate use of specific data types and sets found within standard healthcare transactions produced and transmitted by covered entities (providers, health plans, and clearinghouses). While HHS mandates their administrative use, it officially “adopts” the specific code sets from the designated Maintaining Organizations detailed below:

  • CPT® (Current Procedural Terminology)
    • Administrator: American Medical Association (AMA).
    • Function: This numeric nomenclature is the national standard for reporting medical, surgical, and diagnostic services. It is mandated for all professional and outpatient clinical procedures.
  • HCPCS Level II (Healthcare Common Procedure Coding System)
    • Administrator: Centers for Medicare & Medicaid Services (CMS).
    • Function: This alphanumeric code set is the national standard for identifying products, supplies, and ancillary services not included in the CPT nomenclature, such as durable medical equipment (DME), orthotics, prosthetics, medical supplies, and ambulance services.
  • CPT and HCPCS Modifiers
    • Administrator: American Medical Association (AMA) for CPT modifiers; Centers for Medicare & Medicaid Services (CMS) for HCPCS Level II modifiers.
    • Function: Two-character alphanumeric suffixes appended to CPT or HCPCS procedure codes to provide additional specificity about a service without altering its base definition. Modifiers communicate clinically and administratively significant information — including whether a procedure was altered, performed bilaterally, performed by more than one provider, repeated on the same date of service, or represents a distinct and separately identifiable service. Modifiers are explicitly mandated as a required code set under 45 C.F.R. § 162.1002 and are required fields on both the CMS-1500 professional claim form and the CMS-1450/UB-04 institutional claim form. A code submitted without a required modifier — or with an incorrect modifier — fails HIPAA Title II conformance standards in the same manner as an incorrect base code.
  • ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification)
    • Administrator: The ICD-10-CM Coordination and Maintenance Committee, co-chaired by the National Center for Health Statistics (NCHS/CDC) and the Centers for Medicare & Medicaid Services (CMS).
    • Function: This is the HIPAA-mandated classification system for reporting clinical diagnoses, symptoms, and medical conditions across all United States healthcare settings.
  • ICD-10-PCS (International Classification of Diseases, 10th Revision, Procedure Coding System)
    • Administrator: Centers for Medicare & Medicaid Services (CMS).
    • Function: This is the mandated classification system used exclusively for reporting procedural services performed strictly within hospital inpatient settings.
  • Revenue Codes
    • Administrator: National Uniform Billing Committee (NUBC), maintained via the American Hospital Association (AHA).
    • Function: These four-digit codes are the national standard for identifying specific accommodations, ancillary services, or “cost centers” within a facility (e.g., ICU, Emergency Room, or Pharmacy). They dictate how a hospital must categorize charges on an institutional UB-04 claim form or its electronic equivalent (ASC X12N 837I).
  • NDC (National Drug Code)
    • Administrator: Food and Drug Administration (FDA).
    • Function: The FDA-administered standard for the unique identification and labeling of specific drug products, adopted by HHS as the mandated code set for retail pharmacy transactions under HIPAA Title II.

B. Verification of Administrative Authority

Code set administrators do not merely issue suggestions; they promulgate the official guidelines that covered entities must strictly adhere to for a healthcare transaction to be valid under federal law.

  • Official Maintenance: The above organizations are the HHS-recognized maintaining organizations whose code sets have been adopted by federal regulation, giving their official guidelines the force of law.
  • The Cooperating Parties: For ICD-10 coding specifically, official maintenance and guidelines are governed by the “Cooperating Parties”—a formal joint committee comprising the AHA, AHIMA, CMS, and NCHS. Deviations from the guidelines published by this body constitute a direct violation of the federal transaction standard.
  • Transaction Compliance: Under 45 CFR Part 162, it is non-compliant for a billing entity to utilize local, proprietary, or obsolete codes in place of mandated standard code sets within a commercial or financial transaction.

Because each administrator’s official guidelines govern the definitions, sequencing rules, and modifiers of their respective code sets by virtue of federal regulatory adoption, any financial demand that utilizes these codes while violating those official guidelines constitutes an administrative Non-Conforming Demand.

C. Forensic Determination: Validity of the Financial Demand

Medical Bill Forensics LLC operates under the core principle that a healthcare financial demand (an itemized bill of charges) is only valid, substantiated, and payable if it conforms to HIPAA Title II Administrative Simplification Standards or to contractual negotiations with a health plan.

  • Mandatory Compliance (45 CFR § 162.923): Covered entities are legally required to use the applicable HIPAA Standard Code Sets when conducting standard transactions, which include electronic institutional and professional billing.
  • Administrative Prerequisite to Payment: Adherence to standard nomenclatures, official sequencing rules, and coding guidelines is a foundational prerequisite for provider reimbursement. A code that is non-standard, unbundled, upcoded, or incorrectly sequenced fails to meet federal compliance thresholds. Actions such as unbundling, upcoding, double-billing, and ghost-billing represent healthcare fraud; these actions all use valid HIPAA Title II data elements and segments, but in illegal ways.
  • Status of Non-Conforming Codes: Any line-item charge deviating from these mandatory frameworks is classified as non-conforming. Federal claims processing rules (such as CMS Pub. 100-04) dictate that non-conforming line-items in healthcare transactions are unprocessable and must be Returned to Provider (RTP) for structural correction or removal.
  • Forensic Conclusion: A non-conforming code invalidates the specific line item within the healthcare transaction. A covered entity seeking payment has one path available under federal law: submit a conforming claim supported by original clinical documentation from the date and time of service. Where a code cannot be structurally validated through that documentation, the associated charge cannot be substantiated and is recommended for correction or removal. Until the billing entity produces a conforming, substantiated claim, no payment obligation attaches to that line item under the federal transaction framework.

D. The Forensic Boundary: Itemized Bill Review Only

A foundational pillar of the Medical Bill Forensics LLC methodology is our strict adherence to auditing core billing documents only. We do not request, accept, or review comprehensive patient medical records, clinical provider notes, internal hospital workflows. For our purposes core billing documents are itemized medical bills, explanaton of benefits (EOB) documents from insurers, and CMS-1450-/UB-04 claims documents sent to insurers from providers.

While restricting an audit to the core billing documents may appear counterintuitive to those unskilled in the art, this protocol is intentionally maintained to protect the data privacy of the patient, preserve independent objectivity, and legally allocate the burden of proof. The above core documents, through their data elements and segments, narrate the story of any clinical encounter and if those data elements and segments do not align or are used improperly they are non-conforming under federal law if they were produced by a HIPAA covered entity. Further, billign entities maintain that itemized bills are factual representations of the care delivered to the patient at the time of service and errors or fraud within such documents undermine that position.

  • As an independent forensic auditing firm acting on behalf of the consumer, our analytical scope is restricted to the information within the financial demand itself. Our forensic methodology identifies non-conformance based solely on the structural presence or absence of adherence to standard billign and coding rules; where structural obfuscation makes this impossible, explicit notation is provided within the final forensic report.
  • Protection of Proprietary Software Environments: While federal transparency mandates (including the Consolidated Appropriations Act of 2021 and CMS Hospital Price Transparency rules) require the public disclosure of standard charges, negotiated rates, and chargemasters, internal hospital clinical workflows and proprietary billing algorithms remain a closed “black box.” Medical Bill Forensics LLC cross-references publicly available transparency data to verify baseline rates, but we do not require, nor do we seek, entry into a facility’s internal, live administrative or software environment.
  • Forensic Independence & The Four Corners Rule: We strictly apply the legal Four Corners Rule—a commercial demand for payment must be structurally accurate, legally compliant, and self-substantiating based exclusively on the information presented within the document itself. Digging through clinical charts to retroactively “find” justifications for automated billing errors would amount to performing the hospital’s administrative corrections for them. Remaining outside their clinical workflows ensures our findings represent an entirely objective, third-party evaluation of the hospital’s commercial tender.
  • Preserving the Burden of Proof: The primary mechanism for excluding medical records is to maintain the legal and administrative burden of proof, in the face of billign and coding errors, precisely where it belongs: with billing entity. This process results in two pathways:
  1. Correctable Error: The code is structurally incorrect on the issued bill but can be clinically substantiated by the medical record; this is common in insurance adjudication processes. The billing entity must review its own internal medical records, correct the formatting or sequencing in compliance with official guidelines, and issue a corrected, compliant itemized bill with clinical substantiation that sustains the charge.
  2. Unsubstantiated Charge (potential fraud): The code is incorrect on the issued bill and cannot be substantiated by the clinical documentation because there is no documentation to support the code within the medical record. The non-conforming code and its associated charge must be permanently removed, and a new, corrected bill must be issued reflecting the lower balance.

By auditing the bill alone, Medical Bill Forensics LLC identifies the specific non-conforming line-items that legally halt the consumer’s obligation to pay. We make no determination as to whether a charge could be clinically justified upon billing entity internal review of medical records; the burden to prove clinical substantiation and produce a legally compliant financial demand rests solely and exclusively with the billing entity.

2. Data Intake

Patient-Direct Intake: Medical bill Forensics LLC will only accept itemized medical billing documents directly from a client or thier legally designated agent.

3. Non-Advocacy & Independent Status

Medical Bill Forensics LLC is not a law firm, tax firm, financial firm, debt management company, or HIPAA covered entity (provider, clearinghouse, or health plan). We do not act as a legal representative, agent, or advocate for our clients. We do not engage in direct communication, negotiation, or mediation with any third-party on behalf of a client other than with their legally designated agent. We are not affiliated with, nor do we receive compensation from, any state or federal government.

4. Professional Engagement Limits

The individual receiving a forensic audit is not an ongoing client of Medical Bill Forensics LLC beyond the delivery of a forensic audit report with associated post-audit conference. The delivery of a forensic audit report and reception, or waiver, of a post-audit conference concludes the professional engagement for the specific billing documents reviewed. A virtual, post-audit findings conference is available to the client, or their legally designated agent, should they wish to schedule such a conference and review forensic audit report findings with Medical Bill Forensics LLC. Unless a client, or their legally designated agent, completes the virtual, post-audit conference within ten (10) business days from the date of report delivery to their designated email address they automatically waive the right to the conference. This means that the client is no longer a client of Medical Bill Forensics LLC regardless of anything past the time of 11:59:59 pm on the tenth (10th) business day past delivery a forensic audit report to their designated email address.

5. Indemnification & Use of Audit Findings

The terms “client” and “patient” are used herein; these terms may apply to the same individual but are used differently. Medical Bill Forensics LLC is not a HIPAA covered entity and does not have “patients”; Medical Bill Forensics LLC has clients which may be the individual referred to in the provided billing document as the “patient.” The client is not an ongoing client of Medical Bill Forensics LLC beyond this engagement, and the delivery of this report concludes the professional engagement for the specific billing documents reviewed.

The client agrees to hold harmless and indemnify Medical Bill Forensics LLC from any and all claims, liabilities, or damages arising from the client’s use or distribution of a forensice audit report produced by Medical Bill Forensics LLC, including the distribution of said report to the client’s legal counsel, healthcare advocates, or third-party negotiators. Any use of a forensic audit report produced by Medical Bill Forensics LLC as evidence in a formal dispute, appeal, or legal proceeding is conducted at the discretion and direction of the client and between, or on behalf of, the client and a healthcare provider organization, third-party payer, legal counsel, or healthcare advocate.

Trigger of Liability: The act of utilizing a Medical Bill Forensics LLC forensic audit report — whether for tax record substantiation, achieving a billing reduction, for use in legal proceedings, or for dissemination to third parties (including insurance carriers and healthcare providers) — constitutes a binding agreement by the client to assume all risks associated with such actions. Medical Bill Forensics LLC provides an objective analysis of the clients billing document’s adherence to federal billing standards; however, the strategic application of these findings is at the sole discretion and risk of the client.