Why Do You Need a Medical Billing Expert?

Medical billing experts help lawyers, physicians, and consumers. Here are a few examples of how medical billing experts can assist professionals and patients.

Personal injury plaintiffs are entitled to recover medical expenses from the parties who caused their injuries. While state laws vary, plaintiffs must usually prove two facts: (1) the bills were incurred for medical services that were a necessary response to the injury, and (2) the bills are reasonable. Treating physicians can establish the necessity of the treatment, but courts have often shut down attempts to have physicians testify that their own bills are reasonable.

Ordinary jurors do not have the knowledge or experience to determine whether a medical bill is reasonable. Most courts require expert testimony to prove the reasonableness of a medical bill. While some states presume the reasonableness of medical bills that have been paid, full payment of medical bills by insurance is rare. If defendants will not admit or stipulate to the reasonableness of medical bills, the plaintiff will need to prove that fact with expert testimony.

Courts have become increasingly reluctant to allow a treating physician to testify that billings were reasonable. While a physician might believe that his or her own fees are reasonable, those opinions are not usually grounded in the reliable methodology required by the Daubert standard. When they are cross-examined, physicians usually admit that they have not systematically examined the fees charged by other physicians for similar services in their communities.

Medical billing experts use reliable methodologies to determine whether medical billings are reasonable. Using databases and other information that they collect, medical billing experts compare billings to prices that other physicians in the same community charge for the same services. Medical billing experts help lawyers overcome Daubert challenges by writing detailed reports, demonstrating that they base opinions on reliable data, and explaining how the methodology they use has been accepted by other medical billing experts across the country.

Defendants in personal injury cases — and the insurance companies that provide a defense and pay damages — resist paying medical bills that are unreasonably large. Even when the law in a particular state presumes the reasonableness of paid medical bills, defendants are entitled to challenge that presumption.

Medical billing experts examine billings line by line to determine whether charges are inflated. Medical billing has become so complex that errors are common. Medical billing experts catch mistakes, including double billing for the same service. By comparing medical records to medical billings, billing experts determine whether a clinic or hospital has billed for services that were never provided.

Medical billing relies on standardized codes, including Current Procedural Terminology (CPT) codes. Charges for a service depend upon the code that that was assigned to that service. An incorrect code can result in a larger charge than the provider should have billed. Medical billing experts review every code to determine whether they match the service that was provided.

Physicians commonly “unbundle” services that were provided at the same time by coding them as separate services. Billing for separate services implies that each service was provided separately and that the physician devoted the usual amount of time to the performance of each separate service. When two services are provided at the same time, only one code should be used in the billing, perhaps with a code modifier to reflect any increase in time caused by performing two distinct procedures at the same time.

By identifying coding errors, medical billing experts can help insurance defense lawyers challenge the reasonableness of medical billings. When billings are reduced to a reasonable size, juries and opposing counsel may also deem it appropriate to return a smaller verdict or to settle for a more reasonable amount.

Physicians often retain a medical billing expert when insurance companies unjustly deny their billings. Under some circumstances, insurers have an obligation to pay the usual, customary, and reasonable (UCR) charge for services provided to an insured. Insurers sometimes apply their own payment rates without making any effort to determine the UCR rate.

By using databases and other sources of information, medical billing experts can help physicians prove that their billings are within a reasonable range of UCR rates within the community where the services were provided.

Insurance companies also deny claims because they believe a physician used an incorrect CPT code. A medical billing expert can determine whether an error was made and can help the physician correct the problem so that the billing will be approved. If the billing does not reflect an incorrect CPT code, a billing expert can write a report explaining why the correct code appears on the billing.

It’s no secret that some healthcare providers deliberately overbill their patients, insurance companies, or Medicare for services. They do so by charging for services that were not provided, double billing for the same service, imposing separate charges for services that should have been “bundled” and billed as a single service, or using an incorrect CPT code to describe the service that was provided.

On occasion, patients decide to sue their healthcare providers for fraud. When a healthcare provider makes it a practice to overbill multiple patients in the same way, lawyers might even bring a class action lawsuit against the provider. Medical billing experts provide essential evidence in support of those lawsuits.

Medical billing experts also assist whistleblowers who bring claims under the False Claims Act or an equivalent state law. Whistleblowers who report Medicare or Medicaid fraud often work for the doctors who are responsible for the overbilling. Medical billing experts provide objective evidence to corroborate their whistleblowing claims.

False Claims Act cases generally allow a whistleblower to recover a share of the proceeds. A strong report by a medical billing expert can provide the solid evidence that will convince the government to prosecute the claim. When the U.S. Attorney’s office agrees to step into the lawsuit, the government bears the expense of litigation. The whistleblower’s share of the recovery is reduced, but the odds of bringing a successful claim increase. Either way, the whistleblower’s lawyer has a claim for attorney’s fees if the whistleblower prevails. Medical billing experts are a vital part of any lawyer’s strategy for bringing a successful False Claims Act lawsuit.