Lawyers for plaintiffs and defendants rely on medical billing review experts to prove and defend claims for medical expenses in personal injury cases. Personal injury plaintiffs cannot usually bring a successful claim to recover medical expenses unless they can establish the reasonableness of the plaintiff’s medical bills. A personal injury defendant can often reduce an award of damages by challenging the reasonableness of medical bills. A medical billing review expert can help either the plaintiff or the defendant present an effective case.
How Personal Injury Plaintiffs Use Medical Billing Review Experts
Plaintiffs generally seek the recovery of both special and general damages in personal injury cases. The primary components of special damages are past wage loss, loss of earning capacity, past medical expenses, and future medical expenses.
General damages include pain and suffering. While juries do not follow a formula to compute general damages, studies of trial verdicts have established a relationship between general and special damages. As special damages increase, so do general damages.
It is in a plaintiff’s interest to maximize the recovery of medical expenses. The collateral source rule generally allows plaintiffs to recover those expenses even if they were paid by an insurance company, although the insurer may have a subrogation interest in that recovery. In most jurisdictions, the plaintiff can recover the full amount of billed medical expenses, even if the insurer paid less than the full amount.
As a general rule, a plaintiff may only recover medical bills to the extent that they are reasonable and were incurred for necessary treatment. Necessity is usually proved by the testimony of a treating physician. Reasonableness, on the other hand, often requires proof by a medical billing review expert.
While a physician might be willing to testify that his or her charges are reasonable, a skilled cross-examination will often reveal that the physician has no knowledge of the fees customarily charged for the same services by other physicians in the same community. An uninformed belief that charges are reasonable will be deemed inadmissible in jurisdictions that expect expert opinions to be based on a reasonable methodology and grounded in known facts. Medical billing review experts understand how to formulate opinions about the reasonableness of a billing that satisfy the requirements for admissibility of expert opinions.
In some jurisdictions, medical bills that have been paid are presumed to be reasonable. Other jurisdictions require expert evidence to prove that the bill is reasonable even if an insurer paid it in full or in part. Since insurers rarely pay a full medical bill, a medical billing review expert is usually needed even in jurisdictions that presume the reasonableness of paid medical bills.
How Personal Injury Defendants Use Medical Billing Review Experts
While plaintiffs have an incentive to maximize recoveries, defendants have an incentive to minimize verdicts for damages. An award of medical expenses may be excessive if the award is based on medical billings that are inflated, mistaken, or otherwise unreasonable.
It is a nearly universal rule that juries may only award reasonable medical expenses. While some jurisdictions presume the reasonableness of medical bills that have been paid, those jurisdictions typically permit defendants to challenge that presumption.
Medical bills are unreasonable when billing errors inflate the total charge. Common examples of billing errors include:
- Duplicate billings are made for the same service (double billing)
- A service was billed that was not performed
- Drugs or devices were billed that were not dispensed
- Typographical errors (such as entering 20 instead of 2)
- Upcoding (entering a CPT code for a more expensive service or procedure than the one that was provided)
- Unbundled charges (charging separate fees for services that were provided at the same time and should have been charged under a single code)
Medical bills can also be unreasonable when they exceed the usual, customary, and reasonable (UCR) rate for the billed service. If a bill reflects a higher charge than the same doctor has recently charged other patients for the same procedure, it is not the “usual” charge. If the bill reflects a higher price than is charged by other providers of the same services in the same geographic area, it is not a “customary charge.” A billing that fails either of those two tests is not “reasonable” unless it is justified by a special circumstance.
Medical billing review experts can determine whether there is evidence that a medical bill contains errors or exceeds a UCR rate. Since juries tend to use medical bills as a guide when assessing general damages, reducing an award of medical billings may also result in a lower verdict for pain and suffering.
How Medical Billing Review Experts Analyze Medical Bills
Medical billing review experts perform a line-by-line review of medical billings. They search for duplicate charges and typographical errors that may have resulted in inflated billing.
By comparing medical records to medical billings, medical billing review experts can determine whether charges were assessed for services that were never provided or for drugs and devices that were never dispensed.
Medical billing review experts understand CPT codes and other coding systems that are used in medical billing. Coding is complex. It is easy to make mistakes or to disguise fraud by substituting an incorrect code for a correct code. By comparing services that are documented in medical records to the billing codes that describe those services, medical billing experts are able to determine whether upcoding or unbundling resulted in an excessive bill.
Medical billing review experts rely on databases and their own investigations to determine the usual, customary, and reasonable charges for services in the area where medical services were rendered. Databases provide a wealth of information about customary charges for specific medical services.
A billing for a service that is slightly higher than rates charged by other providers might not be unreasonable. Experts define a charge for a service that is beyond a reasonable range of charges for that service as unreasonable. An objective evaluation of medical billings can assist lawyers for both plaintiffs and defendants in understanding whether a medical billing is reasonable or unreasonable.