Medical Billing Experts in Uninsured Motorist Litigation

Uninsured motorist (UM) claims are governed by contract law, but damages are generally determined by tort law. The contract requires the insurance company to pay the insured injury victim the compensation that the victim would have recovered from the negligent driver if that driver had been insured (subject to the policy limites).

While Florida requires drivers to have personal injury protection (PIP) insurance, that form of no-fault coverage does not cover pain and suffering. When a negligent driver injures the occupant of a vehicle who is covered by PIP insurance, the injury victim will usually be entitled to sue the negligent driver if the victim suffered substantial and permanent injuries.

The right to sue a negligent driver, however, has little value if the negligent driver is uninsured. Most drivers who can’t afford to buy insurance have no significant assets and a minimal income. More than 20% of drivers in Florida have no insurance. Prudent drivers therefore protect themselves by purchasing UM coverage when they buy their PIP insurance.

Like tort claims, the plaintiff who makes a UM claim will seek recovery of past and future medical expenses, as well as the loss of wages and earning capacity, the expense of coping with a disability, and pain and suffering.

Florida courts have held that the recovery of medical expenses in a UM claim follows the same standard of proof that applies in a personal injury claim. The plaintiff must prove not only that the expenses were incurred, but that the medical treatment was a necessary response to injuries caused in the accident. Treating physicians usually supply that proof.

In addition, plaintiffs must prove that the medical expenses incurred were reasonable. Medical expenses are reasonable when they reflect the usual and customary charge for the same services by care providers in the same area.

Care providers know what they charge, but they don’t usually have a firm basis for testifying about the charges of other providers. Lawyers for plaintiffs may therefore turn to medical billing experts to prove the reasonableness of charges.

Insurance companies are allowed to contest the reasonableness of charges. They may save thousands of dollars by doing so. Some judges allow doctors to testify that their charges are reasonable even when the plaintiff cannot lay a foundation for that opinion. Insurance company lawyers turn to medical billing experts to refute that testimony when billings are excessive.

A Florida case illustrates the value of medical billing experts in UM cases. A driver was injured in an accident with an uninsured motorist. The driver sued State Farm for compensation pursuant to the UM coverage of his auto policy. At trial, the driver testified that his medical bills were reasonable. A jury found in the driver’s favor and awarded him more than $900,000. The trial judge then reduced the award to $100,000, the limits of the driver’s UM coverage.

State Farm wanted to present the testimony of a medical billing expert. The expert testified in her deposition that she had been retained to offer opinions “concerning the reasonableness of charges for medical treatment rendered to” the driver. She testified that she compared the bills to the medical treatment records and found “extreme abuse” in the coding and billing compared to the medical record documentation of four of the driver’s main medical care providers.

The expert testified that as to those four providers, “there is absolutely nothing within that documentation that is supportive or representative of any of the billed procedures that I have reviewed.” Her report also indicated that she reviewed $278,000 in medical bills and found that $111,000 in charges did not have any supporting medical codes.

Prior to trial, the judge granted a motion to exclude the medical billing expert’s testimony. The judge decided that the expert’s opinion would not help the jury decide whether the bills were reasonable. The court apparently based that ruling on the expert’s failure to use the word “reasonable” in her deposition testimony.

Of course, witnesses only answer the questions they are asked. If she was not asked whether the bills were reasonable, she can hardly be faulted for failing to answer a question she wasn’t asked. In any event, expert testimony can be helpful even if the expert does not address the ultimate issue that the jury must decide. State Farm, therefore, appealed after the court entered judgment in the driver’s favor based on the jury’s verdict.

The Florida District Court of Appeals concluded that the trial judge erred by excluding the testimony of State Farm’s medical billing expert. State Farm defended the case on the theory that the medical providers fabricated or exaggerated the medical care necessary for the driver’s alleged injuries. The appellate court recognized that the billing expert’s testimony that the bills did not correlate to the treatment in the medical records was relevant to prove State Farm’s defense.

The court of appeals noted that the expert’s proffered testimony related to a technical issue that was beyond the jury’s basic knowledge. The court noted that an understanding of billing codes is beyond the experience of ordinary jurors. The jury had no way to assess State Farm’s defense that the driver was overbilled in the absence of expert testimony. 

The appellate court determined that the medical billing expert was qualified to testify. Her training and experience gave the specialized knowledge that allowed her to express an opinion on whether the medical bills were properly coded and whether they corresponded to the medical records documenting the purported treatment.

The trial court conflated the need to prove that medical services are necessary with the reasonableness of charges for those services. While medical professionals might need to address the issue of necessity, the issue of reasonableness does not require a witness who has medical expertise. A billing expert helps jurors understand whether procedures that were billed are actually documented in medical records. Whether those procedures were necessary is a different question.

Finally, the appellate court emphasized that parties have a due process right to present witnesses that are necessary to prove their claims and defenses. State Farm had the right to present the testimony of a qualified medical billing expert to support its defense that the driver was billed for medical services he never received. The court, therefore, granted State Farm a new trial so that it could present the testimony of a medical billing expert.