What Goes Into Determining the Reasonable Value for Medical Services?

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Medical billing specialists

No one wants to think about their medical bills. The internet is full of anecdotes about the cost of medical treatment, to the point where some people have had Uber drivers take them to the hospital instead of an ambulance when they feel they are having an emergency.

But when you are the plaintiff in a personal injury or medical malpractice case, and you need to prove the amount you have paid for your care and the amount you need to continue to do so in the future, what do you do?

Medical billing specialists can help by reviewing the codes used by providers to denote the services provided, and they can even testify about how much you may owe in the future. Read on to find why enlisting the aid of medical billing specialists will benefit you.

How Is the Reasonable Value of Medical Expenses Determined?

UCR doesn’t refer to a college in California, it is the abbreviation for “Usual, Customary, Reasonable,” which is a three-part approach to determining the value of a medical service that has been provided, and what medical billing specialists use to determine if treatment was billed appropriately.

U – Stands for the “Usual Fee.”  This is the amount that is usually charged by a medical provider for an item like a blood pressure monitor, or a service like bloodwork.

C – Stands for the “Customary Fee” and means that it is the fee that is typically charged by providers in the same specialty, who are also in the same geographical area, for an item or a medical service. This is typically a range that encompasses what other doctors in the patient’s area are charging for their services.

R – Stands for the “Reasonable Fee,” which is the rate for a service deemed necessary under the patient’s circumstances and conditions.

When used together, these terms “usual, customary, and reasonable” refer to the charges made by healthcare practitioners for any given medical service. Charges submitted to insurance are typically considered to be usual, customary, and reasonable if it falls in line with the average cost of that medical treatment within the patient’s geographical area.

These costs are calculated by the health plan administrator or the insurance company and must match the typical amounts charged for the same medical procedures within a specific medical community.  Note that “community” refers to doctors, labs, hospitals, and other health care providers.

This information is used by your health plan and insurance company to decide how much they are willing to reimburse for a medical service in a given geographical area.

The Importance of Understanding the Future Cost of Medical Services

When arguing for a settlement in an injury or medical malpractice case, your plaintiff may have ongoing medical expenses for months, years, or possibly the rest of their life depending on the severity of the damage.

Knowing how much providers charge for their services, and thereby how much the patient will be responsible for, is key to knowing whether the offer by the other party is acceptable. The expenses for a severe car accident that leave a person unable to care for themselves demand far higher compensation than an accident which results in the loss of function for a single finger, for example.

Medical billing specialists will use the Usual, Customary, and Reasonable costs for medical treatment to determine the value of future medical costs so that you can argue from the best position possible for your client.

Medical Insurance and Why It Matters

When a plaintiff in a case is uninsured, it introduces some complications regarding the argument for medical expenses, because they are responsible for the full amount of treatment.

Insured plaintiffs are only responsible for the lowered amount which results after insurance has paid for a portion of the services rendered.

Unfortunately, for those without insurance, the full value of the initial medical bills is not sufficient to prove what their ongoing expenses will be.  Rather, it is necessary to tread carefully with bringing in an expert to discuss the particulars of a medical billing situation.

Having an Expert Testify As To What Is Reasonable In a Case

In many cases, it is advisable to have an expert testify with regard to whether the expenses are reasonable.

This is especially valuable in cases where the treating doctor specializes in pain management or physical therapy and tends to be familiar with the billing codes of their chosen practice and to be aware of special circumstances which arise in their particular field.

Additionally, having medical billing experts testify separately as to the reasonableness of all the medical expenses can be beneficial because they are experts in medical coding and are intimately familiar with the usual, customary, and reasonable rates for treatment. If the medical billing specialists you choose have offices located across the country, they will be better prepared to assist you, as the cost for certain medical treatments varies by the geographical region of the patient.

Why You Need Medical Billing Analysts

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

Whether you are a plaintiff or a defendant in a case, one 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 (MBA) offers litigation support services nationwide, with offices in New York, New Jersey, Connecticut, Pennsylvania, Georgia, Florida, Texas, Nevada & California. Medical Billing Analysts represent 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 the 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.