The Challenge of Establishing Past Medical Expenses – With and Without Insurance

If you were injured and had no medical insurance, the liability you have for your medical treatment is much higher than it would be for someone who was covered by health insurance.  When you are going to trial to argue for economic damages, you need to prove that you are owed reimbursement for the medical bills you incurred, but that can be tricky to do when services were not submitted as claims to an insurance company.

As long as you have the medical bills that you were sent after your treatment was completed, there is hope.  But, you have to be able to show that what your doctors charged you is a fair rate in order to be paid.

You should talk to your lawyer about what the best strategy is for your case, but planning ahead is the most crucial part of your injury case. In this article, we are going to provide key components to making sure your medical bills count for your side in the case.

When you have medical insurance and you require treatment, you are first handled by a provider of services.  Then, a claim for reimbursement is submitted to your insurance company.

Because of the way health insurance works, there are things that your plan will cover completely and there are things that they negotiate discounts for.  So, even if you had a treatment that is not covered, it is possible that you still do not have to pay the full value of the service. 

Only after insurance has paid what they cover and negotiated discounts are accounted for, a bill is issued to the patient by the provider for the remainder of the difference between the cost of care and the insurance reimbursement. People who work in Medical Billing Services deal with claims all the time and are familiar with how much certain services cost in various areas around the country, but a provider may not.

When someone who is uninsured undergoes treatment, they are responsible for the full cost of the care provided to them, but this is where things get tricky. It is not always possible to use the full amount billed to establish “reasonable cost” for treatment, and sometimes having an expert on the subject testify is rejected by the court, so what do you do?

Billed amounts are not always considered “inadmissible.”  Thus, to establish the reasonable cost of services, you have to be careful in the way that the billed amounts are presented. 

Anyone who has to seek medical treatment as a result of injuries takes on liability for the cost of treatment, and therefore suffers a loss economically because insurance does not cover all of the cost of treatment. Reasonable charges that the patient still owes can be recovered in an injury case in the form of economic damages, however, the key word is “reasonable”

If the treating doctor is able to speak to the charges incurred as being a reasonable rate for the treatment provided, then it may be possible to establish that the charges are reasonable. Some doctors who work in a specialized field such as physical therapy are more familiar with the standard rates for treatment they provide than, say, a family medicine practitioner who deals with a wide variety of cases.

Have you ever heard: it isn’t what happened, it’s what you can prove? It is up to the plaintiff or the lawyer arguing on their behalf to prove what the reasonable rate for services is, in order to receive payment as part of the settlement in a case.

The defense lawyers in injury cases are very good at excluding both medical bills and the testimony of treating doctors. That is because the value of medical bills alone does not prove that what the patient was charged was reasonable. Furthermore, a treating doctor is not expected to be an expert in medical billing services, and therefore they may not know what the going rate is for treatments in their area.

If you rely solely on the unpaid medical charges, you will not have successfully substantiated the reasonable value of medical services.

If you are going to have an expert in medical billing services testify in your case, it is imperative that this is part of the pre-trial strategy. While treating doctors should be allowed an opportunity to speak to whether bills are reasonable as to the amounts that are within their knowledge, it is better to declare from the beginning that a particular treating doctor will testify.

As an additional strategy, it is best to have a disclosed expert in medical billing services review the medical bills and testify to the reasonableness of the unpaid medical charges owed by the patient. A medical billing expert will be able to take the U-C-R (usual, customary, and reasonable) rates for services in the patient’s geographic area and make a determination.

It is highly recommended to hire a medical billing and reimbursement expert to determine and testify to the reasonable value of medical service. The provider’s location can affect these costs and reimbursements.

Whether you are a plaintiff or a defendant in a case, o ne of the most important items in Automobile, Personal Injury, and Medical Malpractice cases is the cost of medical bills. Figuring out medical costs can be complicated, and expert guidance is critical to ensuring you have a clear understanding of what is “fair and reasonable” with regards to the finances involved in your medical care.

Medical Billing Analysts offers litigation support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represents both defendants and plaintiffs with regard to improper medical billing and coding.

The team of MBA professionals will review the hospital, medical and therapy bills to determine the value of past medical expenses and based on local CPT codes they can also perform a Cost Projection Analysis of future costs.   Through meticulous analysis, we can justify reasonable cost of services which assists in resolving the case.

Contact Medical Billing Analysts by phone or email at 800-292-1919 or intake@medicalbillinganalysts.com . We’re here for you, whether you need an evaluation of a single charge, or a complex injury case.