The substantive law of personal injury damages is determined by state court precedent. Nearly all states require accident victims who seek recovery of medical bills based on negligence claims to prove that the bills are reasonable. While precedents vary (some states, for example, presume reasonableness to the extent that bills have been paid), proof of reasonableness is generally a condition of recovering past or future medical expenses.
Proof of reasonableness is usually regarded as a procedural issue rather than a question of substantive law. While federal courts must follow state court precedent as to the need to prove reasonableness, the means of proving reasonableness in federal court is usually a matter of federal law. State and federal courts are nevertheless in general agreement that the testimony of medical billing experts may be used to prove reasonableness.
State and federal courts around the country have recognized the importance of expert testimony to prove the reasonableness of medical bills. Florida follows that general trend. The seminal state court case regarding medical billing experts was decided in 2012.
Facts of the Bowling Case
Twyman Bowling was injured in an automobile accident. Unfortunately for Mr. Bowling, the driver of the vehicle who caused the accident was uninsured. Fortunately, Mr. Bowling had uninsured motorist insurance. When his insurer, State Farm, denied his claim, Mr. Bowling sued State Farm to recover damages for his injuries.
Mr. Bowling presented evidence that he received medical bills in the approximate amount of $278,000. A jury awarded $944,154.50 in damages. The trial court reduced that award to the policy limits of $100,000.
A key issue before the jury was whether Mr. Bowling was fabricating or exaggerating his injuries and whether the medical expenses were reasonable. The trial court excluded the testimony of a medical billing expert who would have opined that $111,000 of the medical bills were unsupported by any medical billing codes. Billing codes are used to establish the precise nature of medical services and procedures that were provided. Medicare and private insurance companies typically deny reimbursement for services that are not supported by billing codes.
State Farm’s expert testified in a deposition that she compared the bills to the medical treatment records and found “extreme abuse in regards to the coding, billing, and medical record documentation” of four of Mr. Bowling’s main medical care providers. She testified that as for 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.”
State Farm contended that its billing expert would have provided admissible evidence and that the trial court erred by excluding the expert’s testimony. State Farm appealed the judgment to the Florida District Court of Appeals. The appellate court agreed with State Farm.
Billing Expert’s Proof of Reasonableness
In Florida, as in most states, a plaintiff who wants to recover medical expenses must establish that the billed services were necessary and that the charges were reasonable. Necessity is typically established by the testimony of treating physician’s and is typically challenged with the testimony of medical experts retained by the defense.
Reasonableness, on the other hand, need not be proved with medical testimony. In fact, while doctors may testify that their bills are reasonable, cross-examination often reveals that they have no personal knowledge of the fees charged by other physicians in their community for the same services.
When they profess to have knowledge of a community’s medical billings, doctors often admit that they are basing their opinions on anecdotal evidence rather than a survey of customary charges. Medical billing experts overcome those deficiencies by basing opinions on databases that record charges billed for the same services within the relevant geographic area.
The trial court decided that the medical billing expert was not qualified testify as an expert witness. The appellate court disagreed. The witness had taken specialized courses in medical coding and had passed a national examination in coding. She had sufficiently specialized knowledge and training to express an expert opinion on whether the medical bills were properly coded and whether they corresponded to the medical records documenting the purported treatment. She also had experience testifying as an expert for a variety of lawyers, for the insurance industry, and for various businesses.
The medical billing expert was not qualified to testify whether the medical treatment that was rendered was reasonable, but she was not asked to do that. She was well qualified to opine that the billings reflected treatment that was not documented in the medical records. The expert’s testimony was therefore relevant to State Farm’s defense that Mr. Bowling’s medical providers fabricated or exaggerated the medical care necessary for his alleged injuries.
The appellate court concluded that State Farm had a due process right to present a qualified expert witness who had specialized knowledge that was relevant to its defense. Because the trial court violated State Farm’s right to a fair trial, the court reversed the judgment and remanded the case for a new trial.
Bowling Standard Followed in Florida Cases
State and federal courts in Florida have concluded that the Bowling decision states the law correctly. In 2020, another Florida District Court of Appeal cited Bowling for the proposition that a trial court should exclude a witness only “under the most compelling of circumstances,” especially where excluding the witness will leave a party unable to present evidence supporting her theory of the case.
A federal court recently applied the Bowling standard in a related context. That court allowed a witness to testify as an expert in medical coding when the testimony was relevant to the plaintiff’s false claims case. The plaintiff asserted that the defendant was overbilling the government for medical services.
Applying the federal Daubert standard, the court determined that the medical billing expert formed opinions by applying a reliable methodology to sufficient facts. The court agreed with the plaintiff and with Bowling that a qualified medical billing expert is able to give relevant testimony when the correctness of medical billings is an issue in the case. Thus, in both federal and state courts in Florida, medical billing experts can give admissible testimony when the correctness or reasonableness of medical billings is an issue in the case.