Preview
Electronically Filed
6/19/2020 2:32 PM
Hidalgo County District Clerks
CAUSE NO. CAUSE NO. C-5246—19—D Reviewed By: Mireya Reyna
RAUL J. CANALES and Cm IN THE DISTRICT COURT
EZEQUIEL ROSALES GONZALEZ
Plaintiffs,
VS. 206th JUDICIAL DISTRICT
(03%”an
MS TRANSPORTATION, LLC and
SEBASTIAN S. MACIAS
Defendants. § HIDALGO COUNTY, TEXAS
AFFIDAVIT 0F CAROLE DEVOS
Before me, the undersigned authority, personally appeared CAROLE DEVOS Who, being by me duly
sworn, deposed as follows:
My name is CAROLE DEVOS. I am over 21 years of age, of sound mind and capable of making this
affidavit.
Ihave reviewed the affidavit and medical and billing records of GARCIA CHIROPRACTIC CLINIC.
Based upon my knowledge, skill, experience, training, education and expertise as a certified professional medical
billing coder, GARCIA CHIROPRACTIC CLINIC charges for the services provided to Plaintiff are excessive,
and not Within a range that would be considered reasonable and customary under any metric used t0 Evaluate such
charges.
QUALIFICATIONS
1. | am qualified to controvert the billing records and affidavits as produced based on my knowledge, skill,
experience, training and education.
a. For more than 35 years, | have helped medical providers get paid for the work they perform. My
expertise is in translating medical documentation into specific clinical procedural terminology codes as
provided by the American Medical Association so medical providers get paid for their work. I have set up
Charge Fee Schedules throughout my 35 years of working in the Medical Field to include Facility,
Physician ancl Ancillary providers.
b. | have over 30 years of setting up and monitoring Master Fee/Charge schedules for various providers
that have been cost based as well as market based. These fee schedules and their methodology are
relative to the methodologies used for Usual, Customary and Reasonable Charges by the Texas
1|Page EZEQUéEL ROSALES GONZALEZ
Electronically Filed
6/19/2020 2:32 PM
Hidalgo County District Clerks
Department of Insurance. Reviewed By: Mireya Reyna
c. | have been the Education Officer and President of the Austin, Texas Chapter of the American Association
of Professional Coders (AAPC). Through that organization | have earned certifications as:
Certified Professional Coder (CPC)
Certified Professional Coder - Instructor (CPC-l)
Certified Professional Biller (CPB)
P‘WPWP!‘
Certified Professional Medical Auditor (CPMA)
Certified Hematology and Oncology Coder (CHONC)
\
Certified Professional Compliance Officer (CPCO)
d. | have a Bachelor of Science (BS) degree in Speech Pathology and a Master of Business Administration
(MBA) with a concentration in finance.
e. | have worked as Office Administrator and Business Manager of medical practices that entailed setting
up Charge Master and Fee Schedules for providers for the past 30 years. I
f. | have worked for an Insurance Payor as Senior Provider Representative to address claim and
reimbursement issues as well as State Legislation from the Texas Department of Insurance regarding
Usual, Customary and Reasonable Charges. | would address any complaints from providers rega rding
the methodology used by Prudential for out of network pricing (Usual and Customary determination) for
out of network or non-contracted providers. | worked with both the provider and Texas Department of
Insurance to resolve these issues.
g. Since 1997, | have owned and operated a medical business corporation which provides contracting and
billing services to medical providers and patients. Our complete Revenue Cycle Management services
include:
1. Contracting and Credentialing for Facilities, Groups and Individual Providers- which include fee
reimbursement structure
Medical Billing and Follow-up
Monitoring Procedure and Diagnosis Coding
Ongoing training of providers for proper documentation
9°NP‘P‘P9’N
Identification of Allowances for doubtful accounts (Bad Debt)
Identification of Credit Balances
Collections
Charge Fee Schedule setup - Private Medical Group Practices/ and FQHCs (which is cost based)
with continued monitoring of costs and resetting of the Master Charge schedule annually.
9. Provider Practice Start-ups which include Charge Fee Schedule setting andfinancial pro forma for
the Lending Bank to review.
10. | was the messenger in a Messenger Model IPA-Texas Orthopedic Group from 1998-2001. ln this
position I represented 20 different Orthopedic Groups in the Austin Area. These Groups were
competitors and could not share their fee schedules. l, as an independent agent, would gather all
the fee schedules, negotiate with insurance carriers on the IPA’s behalf and run analysis for each
group ofthe reimbursement relative to market rates, Medicare rates and ran analysis to each
Group’s Charge Master Fee Schedule . | ran analysis on each Group’s Charge schedule against RVU
ZIPage EZEQUIEL ROSALES GONZALEZ
Electronically Filed
6/19/2020 2:32 PM
Hidalgo County District Clerks
values and actual costs spent for a specified time period to ensure the Charge
Reviewed
Schedule By:was
Mireya Reyna
appropriately priced to costs and competitive with current market rates.
11. HealthSouth Corporation- 1995 to 1997
l served as Managed Care Coordinator for the Austin and West Texas markets for three (3) different
types of providers under the HealthSouth Corporation:
a. Out Patient Physical Therapy locations:
a. Entailed at Risk Capitation agreements with carriers which entailed detailed analysis of
the Charge Fee Schedule (Billed Charge) and fee reimbursement amount negotiated.
b. Surgical Hospital
a. Charge Master Review with administrators as was the primary negotiator for the
|
Surgical Hospital, | ensured the Charge Master covered the costs.
c. Rehabilitation Hospital
a. Charge Master Review with administrators as was the primary negotiator for the
|
Rehabilitation Hospital, | ensured the Charge Master covered the costs.
12. Federally Qualified Health Centers (FQHC)
A. Annually review Master Fee Schedule relative to Costs to determine current year’s Master Fee
Schedule.
1. This is mandated by HRSA for FQHC’s to have a fee schedule that covers the cost of services
they provide.
2. Methodologies used are costs relative to total RVU (relative value units) to determine a
clinic’s conversion factor. RVU X Conversion Factor: Billed Charge (Charge Master)
The basis upon which | controvert the billing charges:
Based upon my education, training, certifications, knowledge and years of experience in the medical
field to include knowledge of Fee Schedule setting based both on market and cost based
methodologies, current objective data and Texas Department of Insurance definition of UCR, I provide
the opinions expressed below. Usual Customary and Reasonable Fees were determined by utilization
of Published rates from Medicare and Tricare by Geographic Location and the Texas Department of
Workers Compensation. Bundling Edits were applied to determine the UCR for each procedure
performed.
UCR Definition bv Texas Department of Insurance: Typical amounts charged by providers for
everything from a doctor’s office visit to heart surgery. Health benefit plans commonly will not pay full
benefits if the fees billed by a physician or provider are higher than those charged by other physicians
and providers in the insured area. "Usual and customary" charges may be based on:
(1) typical fees charged by physicians and providers in the insured area;
(2) typical fees compiled by independent rating services; or
(3) typical fees compiled by the insurance company/third-party administrator (TPA).
3|Page EZEQUéEL ROSALES GONZALEZ
Electronically Filed
6/19/2020 2:32 PM
Hidalgo County District Clerks
Texas Department of Insurance: Reviewed By: Mireya Reyna
Under §3.3708(c), reimbursements of all non-preferred providers for services that are covered under
the health insurance policy are required to be calculated pursuant to an appropriate methodology
that:
(1) if based upon usual, reasonable, or customary charges, is based on generally accepted industry
standards and practices for determining the customary billed charge for a service and that fairly and
accurately reflects the market rates, including geographic differences in costs;
(2) if based on claims data, is based upon sufficient data to constitute a representative and
statistically valid sample;
(3) is updated no less than once per year;
(4) does not use data that is more than three years old; and
(5) is consistent with nationally recognized and generally accepted bundling edits and logic.
As a Certified Professional Compliance Officer (CPCO), it is important to note that an excessivefee
schedule (charge amount)falls under the category of Abuse under the Fraud Waste and Abuse
categories and can be subject to fines.
The Texas Department 0f Insurances uses a third party resource (Fair Health) to determine Usual
Customary and Reasonable for out of network claims for Insurance Companies as Texas Insurance
Companies must have a contract with the provider to discount their Billed charges to what is deemed
”reasonable”. This should also translate to consumers or uninsured patients. Fair Health has been
used by carriers to justify their UCR for out of network claims. Recently Texas Department of Insurance
has also selected Fair Health in establishing Usual Customary and Reasonable charges for medical
provider in the State of Texas. This is a new development for Texas and occurred in 2018 and was not
in effect for the dates of service in this case.
Currently Fair Health is at 125% ofthe Median allowable charge for Usual Customary and Reasonable
(UCR) for other geographic areas. This changes year to year.
Factors to consider for setting Usual Customary and Reasonable Charges (Billed Charges)
1. Procedures performed by providers are translated into CPT/HCPC Coding
2. Each Code has a Relative Value Unit (RVU) that is standardized with input from the American
Medical Association- Objective Data
3. A conversion factor is used to multiple the RVU to determine a fair and reasonable
reimbursement/billed charge amount. This same methodology is used to price a Charge
Master/Fee Schedule that is not excessive but covers the provider’s costs while maintaining a fair
profit margin. Costs for a specified period must be provided to calculate a reasonable Charge
Schedule if the charge schedule is above the market area fee schedules relative to the provider‘s
peers in a specified region.
4. A Provider will have a standard fee schedule that it bills to insurance companies and patients.
**These Standard Fee Schedules (Charge Master) were requested for each provider but were not
provided.
Costs and CPT Procedure Utilization were not provided.
4|Page EZEQLHEL ROSALES GONZALEZ
Electronically Filed
6/19/2020 2:32 PM
Hidalgo County District Clerks
Reviewed By: Mireya Reyna
The following industry standards were utilized to formulate a fair and reasonable reimbursement amount per
procedure:
1. NCCI Edits— National Correct Coding Initiative was created by CMS to promote correct coding and
methodologies and control improper assignment of codes ASC and OPPS groupings for facility charges.
Assistant Surgery guidelines.
Multiple Procedure Guidelines.
P‘P‘PP’N
Bilateral Procedure Guidelines
Bundling Edits
Medically Unlikely Edits which define the maximum units of service that a provider would report,
under most circumstances, for a single beneficiary, on a single date of service for a specific HCPCS/CPT
code.
Global periods for surgical procedures.
Facility charges based on MS-DRG reimbursement methodology.
a. OPPS/APC
b. Asc
c. Ms-DRG
The calculations for the UCR for this case was based on the public fee schedules of Medicare/Tricare
and Texas Workers Compensation. These were averaged out to derive the UCR for each procedure
code submitted by each provider. Standardized Bundling Edits (NCCI) were utilized which may have
lowered the UCR charge amount. GARCIA CHIROPRACTIC CLINIC charges range from 222.62% to
% over the determined UCR (as indicated in the above methodologies) which are deemed excessive.
Further affiant sayeth not.
fléflWa 6V
EKfiOLE bBVQ
SWORN To AND SUBSCRIBED by game m Dcvos ,on the l”! day of Jun; ,2020
to certify which witness my hand and seal of office.
§$
\I‘
m
$6
ow Poo
J
“
t
AVERYMWILLIAMS
Notary ID #132235053
MyNgzzggfr‘fi“ 5332'“
MW Wm
Notary Pulflic‘ for
INA
-
the. State
k
of Texas
My Comm1ss1on explres: H / 0! l
26
5|Page EZEQUIEL ROSALES GONZALEZ
Preview
Electronically Filed 6/19/2020 2:32 PM Hidalgo County District Clerks CAUSE NO. CAUSE NO. C-5246—19—D Reviewed By: Mireya Reyna RAUL J. CANALES and Cm IN THE DISTRICT COURT EZEQUIEL ROSALES GONZALEZ Plaintiffs, VS. 206th JUDICIAL DISTRICT (03%”an MS TRANSPORTATION, LLC and SEBASTIAN S. MACIAS Defendants. § HIDALGO COUNTY, TEXAS AFFIDAVIT 0F CAROLE DEVOS Before me, the undersigned authority, personally appeared CAROLE DEVOS Who, being by me duly sworn, deposed as follows: My name is CAROLE DEVOS. I am over 21 years of age, of sound mind and capable of making this affidavit. Ihave reviewed the affidavit and medical and billing records of GARCIA CHIROPRACTIC CLINIC. Based upon my knowledge, skill, experience, training, education and expertise as a certified professional medical billing coder, GARCIA CHIROPRACTIC CLINIC charges for the services provided to Plaintiff are excessive, and not Within a range that would be considered reasonable and customary under any metric used t0 Evaluate such charges. QUALIFICATIONS 1. | am qualified to controvert the billing records and affidavits as produced based on my knowledge, skill, experience, training and education. a. For more than 35 years, | have helped medical providers get paid for the work they perform. My expertise is in translating medical documentation into specific clinical procedural terminology codes as provided by the American Medical Association so medical providers get paid for their work. I have set up Charge Fee Schedules throughout my 35 years of working in the Medical Field to include Facility, Physician ancl Ancillary providers. b. | have over 30 years of setting up and monitoring Master Fee/Charge schedules for various providers that have been cost based as well as market based. These fee schedules and their methodology are relative to the methodologies used for Usual, Customary and Reasonable Charges by the Texas 1|Page EZEQUéEL ROSALES GONZALEZ Electronically Filed 6/19/2020 2:32 PM Hidalgo County District Clerks Department of Insurance. Reviewed By: Mireya Reyna c. | have been the Education Officer and President of the Austin, Texas Chapter of the American Association of Professional Coders (AAPC). Through that organization | have earned certifications as: Certified Professional Coder (CPC) Certified Professional Coder - Instructor (CPC-l) Certified Professional Biller (CPB) P‘WPWP!‘ Certified Professional Medical Auditor (CPMA) Certified Hematology and Oncology Coder (CHONC) \ Certified Professional Compliance Officer (CPCO) d. | have a Bachelor of Science (BS) degree in Speech Pathology and a Master of Business Administration (MBA) with a concentration in finance. e. | have worked as Office Administrator and Business Manager of medical practices that entailed setting up Charge Master and Fee Schedules for providers for the past 30 years. I f. | have worked for an Insurance Payor as Senior Provider Representative to address claim and reimbursement issues as well as State Legislation from the Texas Department of Insurance regarding Usual, Customary and Reasonable Charges. | would address any complaints from providers rega rding the methodology used by Prudential for out of network pricing (Usual and Customary determination) for out of network or non-contracted providers. | worked with both the provider and Texas Department of Insurance to resolve these issues. g. Since 1997, | have owned and operated a medical business corporation which provides contracting and billing services to medical providers and patients. Our complete Revenue Cycle Management services include: 1. Contracting and Credentialing for Facilities, Groups and Individual Providers- which include fee reimbursement structure Medical Billing and Follow-up Monitoring Procedure and Diagnosis Coding Ongoing training of providers for proper documentation 9°NP‘P‘P9’N Identification of Allowances for doubtful accounts (Bad Debt) Identification of Credit Balances Collections Charge Fee Schedule setup - Private Medical Group Practices/ and FQHCs (which is cost based) with continued monitoring of costs and resetting of the Master Charge schedule annually. 9. Provider Practice Start-ups which include Charge Fee Schedule setting andfinancial pro forma for the Lending Bank to review. 10. | was the messenger in a Messenger Model IPA-Texas Orthopedic Group from 1998-2001. ln this position I represented 20 different Orthopedic Groups in the Austin Area. These Groups were competitors and could not share their fee schedules. l, as an independent agent, would gather all the fee schedules, negotiate with insurance carriers on the IPA’s behalf and run analysis for each group ofthe reimbursement relative to market rates, Medicare rates and ran analysis to each Group’s Charge Master Fee Schedule . | ran analysis on each Group’s Charge schedule against RVU ZIPage EZEQUIEL ROSALES GONZALEZ Electronically Filed 6/19/2020 2:32 PM Hidalgo County District Clerks values and actual costs spent for a specified time period to ensure the Charge Reviewed Schedule By:was Mireya Reyna appropriately priced to costs and competitive with current market rates. 11. HealthSouth Corporation- 1995 to 1997 l served as Managed Care Coordinator for the Austin and West Texas markets for three (3) different types of providers under the HealthSouth Corporation: a. Out Patient Physical Therapy locations: a. Entailed at Risk Capitation agreements with carriers which entailed detailed analysis of the Charge Fee Schedule (Billed Charge) and fee reimbursement amount negotiated. b. Surgical Hospital a. Charge Master Review with administrators as was the primary negotiator for the | Surgical Hospital, | ensured the Charge Master covered the costs. c. Rehabilitation Hospital a. Charge Master Review with administrators as was the primary negotiator for the | Rehabilitation Hospital, | ensured the Charge Master covered the costs. 12. Federally Qualified Health Centers (FQHC) A. Annually review Master Fee Schedule relative to Costs to determine current year’s Master Fee Schedule. 1. This is mandated by HRSA for FQHC’s to have a fee schedule that covers the cost of services they provide. 2. Methodologies used are costs relative to total RVU (relative value units) to determine a clinic’s conversion factor. RVU X Conversion Factor: Billed Charge (Charge Master) The basis upon which | controvert the billing charges: Based upon my education, training, certifications, knowledge and years of experience in the medical field to include knowledge of Fee Schedule setting based both on market and cost based methodologies, current objective data and Texas Department of Insurance definition of UCR, I provide the opinions expressed below. Usual Customary and Reasonable Fees were determined by utilization of Published rates from Medicare and Tricare by Geographic Location and the Texas Department of Workers Compensation. Bundling Edits were applied to determine the UCR for each procedure performed. UCR Definition bv Texas Department of Insurance: Typical amounts charged by providers for everything from a doctor’s office visit to heart surgery. Health benefit plans commonly will not pay full benefits if the fees billed by a physician or provider are higher than those charged by other physicians and providers in the insured area. "Usual and customary" charges may be based on: (1) typical fees charged by physicians and providers in the insured area; (2) typical fees compiled by independent rating services; or (3) typical fees compiled by the insurance company/third-party administrator (TPA). 3|Page EZEQUéEL ROSALES GONZALEZ Electronically Filed 6/19/2020 2:32 PM Hidalgo County District Clerks Texas Department of Insurance: Reviewed By: Mireya Reyna Under §3.3708(c), reimbursements of all non-preferred providers for services that are covered under the health insurance policy are required to be calculated pursuant to an appropriate methodology that: (1) if based upon usual, reasonable, or customary charges, is based on generally accepted industry standards and practices for determining the customary billed charge for a service and that fairly and accurately reflects the market rates, including geographic differences in costs; (2) if based on claims data, is based upon sufficient data to constitute a representative and statistically valid sample; (3) is updated no less than once per year; (4) does not use data that is more than three years old; and (5) is consistent with nationally recognized and generally accepted bundling edits and logic. As a Certified Professional Compliance Officer (CPCO), it is important to note that an excessivefee schedule (charge amount)falls under the category of Abuse under the Fraud Waste and Abuse categories and can be subject to fines. The Texas Department 0f Insurances uses a third party resource (Fair Health) to determine Usual Customary and Reasonable for out of network claims for Insurance Companies as Texas Insurance Companies must have a contract with the provider to discount their Billed charges to what is deemed ”reasonable”. This should also translate to consumers or uninsured patients. Fair Health has been used by carriers to justify their UCR for out of network claims. Recently Texas Department of Insurance has also selected Fair Health in establishing Usual Customary and Reasonable charges for medical provider in the State of Texas. This is a new development for Texas and occurred in 2018 and was not in effect for the dates of service in this case. Currently Fair Health is at 125% ofthe Median allowable charge for Usual Customary and Reasonable (UCR) for other geographic areas. This changes year to year. Factors to consider for setting Usual Customary and Reasonable Charges (Billed Charges) 1. Procedures performed by providers are translated into CPT/HCPC Coding 2. Each Code has a Relative Value Unit (RVU) that is standardized with input from the American Medical Association- Objective Data 3. A conversion factor is used to multiple the RVU to determine a fair and reasonable reimbursement/billed charge amount. This same methodology is used to price a Charge Master/Fee Schedule that is not excessive but covers the provider’s costs while maintaining a fair profit margin. Costs for a specified period must be provided to calculate a reasonable Charge Schedule if the charge schedule is above the market area fee schedules relative to the provider‘s peers in a specified region. 4. A Provider will have a standard fee schedule that it bills to insurance companies and patients. **These Standard Fee Schedules (Charge Master) were requested for each provider but were not provided. Costs and CPT Procedure Utilization were not provided. 4|Page EZEQLHEL ROSALES GONZALEZ Electronically Filed 6/19/2020 2:32 PM Hidalgo County District Clerks Reviewed By: Mireya Reyna The following industry standards were utilized to formulate a fair and reasonable reimbursement amount per procedure: 1. NCCI Edits— National Correct Coding Initiative was created by CMS to promote correct coding and methodologies and control improper assignment of codes ASC and OPPS groupings for facility charges. Assistant Surgery guidelines. Multiple Procedure Guidelines. P‘P‘PP’N Bilateral Procedure Guidelines Bundling Edits Medically Unlikely Edits which define the maximum units of service that a provider would report, under most circumstances, for a single beneficiary, on a single date of service for a specific HCPCS/CPT code. Global periods for surgical procedures. Facility charges based on MS-DRG reimbursement methodology. a. OPPS/APC b. Asc c. Ms-DRG The calculations for the UCR for this case was based on the public fee schedules of Medicare/Tricare and Texas Workers Compensation. These were averaged out to derive the UCR for each procedure code submitted by each provider. Standardized Bundling Edits (NCCI) were utilized which may have lowered the UCR charge amount. GARCIA CHIROPRACTIC CLINIC charges range from 222.62% to % over the determined UCR (as indicated in the above methodologies) which are deemed excessive. Further affiant sayeth not. fléflWa 6V EKfiOLE bBVQ SWORN To AND SUBSCRIBED by game m Dcvos ,on the l”! day of Jun; ,2020 to certify which witness my hand and seal of office. §$ \I‘ m $6 ow Poo J “ t AVERYMWILLIAMS Notary ID #132235053 MyNgzzggfr‘fi“ 5332'“ MW Wm Notary Pulflic‘ for INA - the. State k of Texas My Comm1ss1on explres: H / 0! l 26 5|Page EZEQUIEL ROSALES GONZALEZ