Medical Billing Review Expert in Medical Malpractice Cases

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Like any other personal injury case, medical malpractice victims are entitled to recover reasonable medical expenses they incur as a result of their physician’s negligence. Medical billing review experts help lawyers prove or disprove the reasonableness of those expenses.

Unlike most other personal injury cases, a medical billing review expert might be able to help lawyers prove that malpractice occurred. A careful comparison of medical records to billing records will sometimes provide evidence that the medical records were altered, perhaps to cover up negligence.

Proving the Reasonableness of Medical Expenses

Medical malpractice may result in prolonged care to alleviate the harm caused by the negligent doctor. Surgical malpractice may result in surgical revisions. Prescribing a medication overdose or a medication to which a patient has an allergy may require further hospitalization to treat the resulting harm. The expense of diagnosing and treating harms caused by malpractice is an element of the malpractice victim’s damages.

State law typically requires an injury victim who seeks reimbursement of medical expense to prove that the expenses were reasonable and necessary. A treating physician can explain why the billed treatment was necessary. Treating physicians, on the other hand, may not be well positioned to testify about the reasonableness of medical expenses.

Medical expenses are reasonable when they are the usual and customary charge for a medical service or procedure. The “usual” fee is the fee that the same provider charges other patients for the same services. The “customary” fee is the fee that other providers charge for the same services in the same geographic area. Treating physicians might know what they usually charge for a service, but they rarely have more than anecdotal knowledge of the fees that other physicians charge for the same services.

Since ordinary jurors do not know whether a particular charge for a medical service is reasonable, plaintiffs must typically present expert evidence to establish reasonableness. Judges who take a strict view of Daubert and similar state standards for the admission of expert testimony will not accept a doctor’s unsupported opinion that “My charges are reasonable.” 

The Daubert standard requires an expert opinion to be based on sufficient facts, a reliable methodology, and the reliable application of the methodology to the facts. A physician who has not surveyed the fees charged by other doctors lacks sufficient facts to support an opinion.

Nor do physicians base their opinions on a reliable methodology when they express a personal opinion that their fees are reasonable. Courts increasingly reject that testimony because it is unsupported by a reliable method for reaching conclusions.

Medical billing experts overcome Daubert objections by basing their conclusion on sufficient facts and a reliable methodology. To form an opinion about the reasonableness of a billing, they compare the billing codes to the medical records to determine the billing’s accuracy. They then consult established databases to determine the fees charged by other physicians in the same community for the same services as those that were billed. 

If the bill is accurate and if it falls within the range of fees charged by other physicians, the bill is reasonable. If the bill is inaccurate or if it is substantially higher than the fees charged by other physicians, it is likely unreasonable unless there is a credible explanation for the higher fee.

Medical billing review experts, unlike most physicians, base their opinions on standardize methods that are accepted within their field of expertise and that produce reliable results. For that reason, judges routinely admit the opinion testimony of medical billing review experts.

Proving Malpractice

Lawyers primarily rely on medical experts to establish a standard of care, a breach of that standard, and the causal link between the breach and the injury. A thorough expert review of medical billings will sometimes add additional evidence that cements the plaintiff’s case.

Studies of doctors who commit malpractice have concluded that doctors frequently attempt to conceal their mistakes or shift the blame to the patient or other doctors rather than admitting their errors. Doctors who do not want to impair their professional reputations may alter medical records to hide their mistakes. Hospital administrators sometimes encourage or abet the physician’s deception to protect the hospital from liability.

Surveys have found that 7% of doctors believe it is acceptable to hide errors from patients, while another 14% feel it is acceptable to hide the truth under some circumstances. In reality, the surveys probably undercount the extent of physician dishonesty. It is easy for a physician to tell someone taking a survey that he or she would never conceal a mistake. When push comes to shove, however, a certain percentage of physicians who thought of themselves as honest will take the path of self-interest.  

Altering medical records is the most common way to conceal medical negligence. Doctors might change medication records to make it appear that they prescribed a different medication than the one that was administered to a hospitalized patient. They might alter patient histories to make it appear that a patient never told them about an allergy. They might indicate that they advised a patient to obtain a test that the doctor never discussed with the patient.

In some cases, altered medical records result in “doctor said – patient said” credibility contests. In a percentage of those cases, a medical billing expert can detect evidence that the patient records were changed.

Billing records contain diagnostic and procedural codes. Billings are often issued before a physician changes medical records to conceal a mistake. It is less easy to change diagnostic and procedural codes since billings have already been sent to the patient and the patient’s insurer.

If medical records show that a doctor made a diagnosis when a lawsuit contends the doctor erroneously failed to make the diagnosis, the absence of that diagnostic code in the billing records may be evidence that the medical records were altered. If medical records show that services were provided or procedures were performed that are not reflected in billing codes, the absence of those codes may also be evidence that the records were changed.

Evidence that medical records were altered can be compelling evidence that challenges a physician’s credibility. Medical billing review experts can thus help prove liability in some malpractice cases.