Lawyers for plaintiffs and defendants face challenges when plaintiffs seek reimbursement of medical bills as damages in a motor vehicle accident case. Plaintiffs must prove that the bill is reasonable. Defendants might face a presumption that any portion of the bill that was paid by insurance or the plaintiff is reasonable. Even when that presumption does not arise, defendants have an incentive to reduce the verdict by presenting evidence that the bill is unreasonable.
A medical billing review by a qualified billing expert in vehicular accident cases serves multiple purposes. First, the review alerts the attorney to potential issues related to the recovery or defense of medical expenses as an element of damages. Second, the review highlights expert opinions that lawyers can offer in court to prove or defend against a claim for medical expense reimbursement. Third, medical billing reviews promote settlement by giving lawyers a better understanding of the amount of medical expenses that a jury is likely to award.
Proof of Reasonable Medical Bills
Plaintiffs who are injured in motor vehicle accidents because of a driver’s negligence are entitled to recover reasonable and necessary medical expenses that they incurred because of the defendant’s negligence. Causation is typically proved with a combination of fact witnesses, treating physicians, and (on occasion) expert witnesses who testify that that the accident caused the injuries for which the plaintiff was treated. Necessity is usually proved by a treating physician’s testimony that the billed services were required to diagnose and treat those injuries.
The reasonableness of those charges, on the other hand, cannot necessarily be established by medical testimony. When the bills are small, parties might stipulate that they are reasonable. A defendant might also respond to a request for admissions by admitting that the charges are reasonable. When bills are more substantial, however, whether they are reasonable is often a disputed issue.
In some courts, a judge who has a lax attitude about the proof of reasonableness might allow a doctor to testify that his or her charges were reasonable. However, judges increasingly agree that “I think my fees are reasonable” is not an adequate foundation for an opinion that fees are reasonable.
Medical bills are reasonable when the charges are consistent with the usual and customary fees charged by other providers of the same services in the same community. The “usual” fee is the fee that the same provider charges other patients for the same services. The “customary” fee is the fee that comparable providers charge for the same services in the same geographic area. Expert testimony is often essential to establish that medical bills are reasonable.
Using an Expert to Prove that Medical Expenses Are Reasonable
It is risky to use a treating physician to prove that the physician’s fees are reasonable. Physicians usually have no knowledge of charges other than their own, including hospital bills. Doctors often admit on cross-examination that they have not surveyed other doctors in their area to determine the amount they charge for the same services that are reflected in a medical billing. They might have anecdotal conversations with other doctors, but they have not used a reliable methodology to determine whether their charges are reasonable.
In federal court, and increasingly in state courts that have adopted some version of the Daubert rules, judges are declining to admit a doctor’s personal opinion that his or her charges are reasonable. The Daubert standard requires qualified experts to base opinions on sufficient facts and on a reliable methodology that they apply to the facts in a reliable way.
Since jurors do not know whether billed charges are consistent with usual and customary charges within a community, reasonableness must be proved by an expert opinion. Expert opinions must be based on reliable methodologies and supported by adequate facts. Opinions based on anecdotal evidence do not meet that standard.
Courts recognize that medical billing experts are qualified when they have training and experience that most people lack. Familiarity with billing and diagnostic codes gives medical billing experts specialized knowledge that ordinary jurors do not possess. Courts agree that medical billing experts do not need medical training to qualify as expert witnesses.
Medical billing experts gather sufficient facts and data by reviewing medical records, billings, and databases that record the actual costs of specific medical services within a community. Courts consider those facts to be sufficient to support an expert’s analysis of a medical billing.
Medical billing experts also derive their opinions from reliable methodologies. They use databases to determine the actual prices charged by other physicians in the same area for the same services. That analysis allows the expert to determine whether the medical billing falls within a reasonable range of charges for the same services or is substantially higher.
As all medical billing experts use the same fundamental principles to determine whether charges are reasonable, their methodology is widely accepted as reliable within their field of expertise. Eliciting testimony about the expert’s methodology and training provides the court with a basis for determining that the expert’s opinion satisfies the Daubert standard.
Using an Expert to Defend Against Claims that Medical Expenses Are Reasonable
Even when a jurisdiction presumes the reasonableness of paid bills, defendants are allowed to challenge that presumption. Defendants are also free to challenge the reasonableness of bills that an insurer did not pay, even if the collateral source rule allows plaintiffs to recover medical expenses that a provider will never attempt to collect.
In addition to reviewing medical bills for reasonableness, billing experts determine whether a provider has made billing errors that result in an overcharge. Experts perform a line-by-line analysis of medical bills, looking for double charges or mistakes (such as data entry errors) that result in erroneous charges. They compare medical records to medical billings to determine whether the billing reflects the services that were provided.
Medical billing experts rely on their understanding of billing codes to assure that the billing does not reflect a more expensive service than the service that the patient received. They examine billings for “unbundling” errors that occur when doctors use billing codes for separate services that were provided at the same time. Since lay members of a jury are not trained to interpret billing codes, expert knowledge provides the foundation of the expert’s opinion.