Why Are Medical Billing Expert Opinions Admissible as Evidence?

Lawyers use medical billing experts in a variety of legal proceedings. In personal injury cases, plaintiffs must typically prove that the medical expenses they seek to recover are reasonable. Defendants, on the other hand, often challenge the reasonableness of medical bills that appear to be inflated. Medical billing experts can assess bills for either a plaintiff or a defendant to offer an objective opinion whether the bill reflects procedures that were actually provided, whether the billing codes that determine charges are accurate, and whether the billing is consistent with the usual, customary, and reasonable charges within the same geographic area for the same services.

In false claim proceedings, medical billing experts help whistleblowers establish that a medical provider overbilled Medicare, Medicaid, or another government agency for medical services. Lawyers use their expert analysis to establish a pattern of using CPT codes that do not reflect the actual procedures and services that were rendered. Lawyers can establish an inference of fraud based on patterns of overbilling that medical billing experts document.

In medical malpractice cases, medical billing experts can uncover evidence that medical records were changed in an effort to cover up a health care provider’s mistake. It is easier to alter a medical record than it is to change a billing that has already been submitted to an insurer.

In all of those cases, and in any other case when medical billings may be introduced into evidence, medical billing experts can provide vital evidence. Fortunately, courts have routinely agreed that medical billing experts satisfy the evidentiary standard that governs the admission of expert testimony.

The Federal Rules of Evidence and every state evidence code permit expert testimony while placing limitations on its admissibility. All jurisdictions agree that expert testimony is only admissible if it helps the jury understand relevant facts. If ordinary people are capable of understanding the evidence, expert testimony is not necessary.

All jurisdictions also agree that expert witnesses must be qualified to give expert testimony. Experts can be qualified by virtue of their education, training, and experience.

In the federal system, expert testimony must also satisfy the Daubert standard. Federal judges determine whether the proposed testimony is sufficiently reliable to warrant consideration by a jury. Reliability is a function of: (1) the expert’s consideration of sufficient facts to form an opinion, (2) the expert’s use of a reliable methodology to form opinions, and (3) the expert’s application of the methodology to the facts in a reliable way.

Most states have adopted some form of the Daubert standard, although many have merged the standard with evidentiary standards that predated Daubert . Although the Daubert standard applies to both scientific evidence and to expert evidence that is not based on science, judges have been noticeably more stringent in applying Daubert to science-based testimony.

Before Daubert became the reigning standard of admissibility, federal courts and most states followed the Frye standard. That standard is still the law in some states. It allows the admission of expert testimony if the expert’s methods are generally accepted by other experts in the same field. Other states have adopted a hybrid of Daubert and Frye or have taken their own unique approach to the admission of expert testimony.

Courts routinely find that medical billing experts have unique knowledge that most jurors lack. The charges for medical services depend on the Current Procedural Terminology (CPT) code that the biller assigned to each billed service or procedure. Assigning the wrong code will often result in an overbilling.

For example, medical billing experts review medical bills for upcoding. When medical records describe a specific medical procedure but the billing shows a CPT code for a more complex (and thus more expensive) procedure, the patient will be overbilled. The problem of upcoding, whether deliberate or accidental, is common in medical billings. An ordinary juror, however, lacks an understanding of the thousands of CPT codes that medical billers use to identify procedures and services. Medical billing experts are familiar with medical procedures and with the specific CPT code that should be applied to each medical procedure or service that appears on a medical bill.

Another common billing error is known as unbundling. Doctors sometimes perform more than one procedure at the same time. When those procedures are performed separately, the total time it takes to perform them is greater than when they are performed together. Consequently, using the CPT code for a set of “bundled” procedures will result in a lower price than using separate CPT codes for each “unbundled” procedure. Medical billing experts are trained to detect unbundling and to identify the erroneous use of multiple CPT codes when bundled procedures should be covered by a single CPT code.

Medical billing experts are trained in medical terminology. They have a basic understanding of anatomy, physiology, and pathology. They are qualified to read medical records and to identify specific medical services and procedures that were delivered to patients.

Medical billing experts are also trained to identify the correct and incorrect use of CPT codes. In addition, they are familiar with specialized databases that record the prices that physicians in a community charge for medical services. That specialized training qualifies medical billing experts to express opinions about the accuracy and reasonableness of medical billings.

Reliability is the key to admissibility in jurisdictions that rely on Daubert . Medical billing experts use methodologies that are commonly accepted within their field of expertise. They thus satisfy both the Frye standard and one of the measures of reliability that Daubert courts employ. 

The methodology requires billing experts to gather adequate facts from medical records, to compare those records to medical billings, and to determine whether the medical procedures and services provided match the CPT codes in the medical billings. The methodology then requires billing experts to use databases that are standard in the field and to compare the doctor’s billing for services to usual and customary charges to assess reasonableness. Since medical billing experts are able to explain why their methodology produces reliable results, courts routinely allow medical billing experts to offer opinions about the accuracy and reasonableness of medical bills.