Working Together: A Guide for Medical Experts and Medical Billing Experts

Medical experts provide opinions in litigation involving personal injuries, wrongful death, medical malpractice, sexual and domestic abuse, and other medical harms. They help lawyers establish economic and noneconomic harms, usually by offering opinions about the cause of an injury, the necessity of medical treatment that the victim received for that injury, the likely need for future treatment.

Medical bills are part of the injury victim’s economic damages. To recover medical bills, most states require the plaintiff to prove that the medical expenses were necessary and reasonable. Medical experts — usually treating physicians — can testify about the necessity of treatment. However, lawyers generally rely on medical billing experts to prove that billings were reasonable.

Personal injury cases typically depend on medical experts to establish the extent of an accident victim’s injuries. Treating physicians are the most common medical experts in personal injury cases. In federal court, a treating physician is classified as a non-retained expert. Non-retained experts are not required to produce the detailed reports that civil procedure rules demand of retained experts. Treating physicians testify about the injuries they observed, the diagnosis they made, the treatment they rendered, and the recommendations they made for future treatment. 

A treating physician might also give causation testimony by stating whether the injuries the physician observed are consistent with injuries that could be caused by the car accident that other witnesses describe. When a treating physician is uncomfortable expressing opinions about causation, or when a judge rules that the treating physician may not do so, it may be necessary to retain a medical expert to give that testimony. Retained medical experts also testify in personal injury cases when a specialist needs to be hired to opine about future treatment needs and the cost of such treatment. 

Retained medical experts are common in medical malpractice litigation. Medical experts are hired as witnesses to testify about the standard of care that applies to a doctor who practices in a given specialty. The expert witness will also review the defendant doctor’s performance and express an opinion whether the defendant breached that standard of care.

Depending on state law, medical experts play varying roles in workers’ compensation proceedings. In most cases, treating physicians prepare reports that describe work-related injuries. They engage in functional capacity evaluations and define work limitations based on workplace injuries. Medical experts may play critical roles in assigning disability ratings. Some states give employees the opportunity to retain medical experts to conduct independent evaluations, while other states are more restrictive about the employee’s right to introduce the opinions of retained medical experts.

Sexual and domestic abuse lawsuits depend on medical experts to testify about physical symptoms of abuse and its psychological consequences. Lawsuits against institutions (including schools and churches) that employ sexual predators often rely on psychiatrists and other medical experts to explain the lasting impact of childhood sexual abuse on adult survivors.

Medical experts testify in wrongful death and survival actions to establish cause of death, the time span between the accident and death, whether the victim was conscious during that time span, and medical efforts to save the victim’s life. Wrongful death lawsuits often involve substantial medical bills for medical treatment prior to death that the victim’s estate seeks to recover.

Recovering medical expenses requires proof that the expenses are reasonable and necessary. A combination of medical experts and medical billing experts is needed to establish those elements.

The necessity of treatment is the province of a medical expert. Treating physicians are often in the best position to explain why the treatment they rendered was a necessary response to the injuries they diagnosed.

The reasonableness of medical expenses, however, is not usually an opinion that medical experts are qualified to render. Reasonableness is a function of two factors: the usual price for a service that the physician charges her other patients, and the customary price charged for the same service by other physicians in the community. A treating physician might be able to testify that about his usual charges but has probably not conducted the kind of expert analysis that is required to form an opinion about the customary charge.

Many courts have determined that medical experts cannot satisfy the Daubert standard when they propose to offer expert opinions about the reasonableness of their charges. Daubert requires expert opinions to be based on a reliable application of a reliable methodology to sufficient facts. The “sufficient facts” that support a reasonableness analysis are the prices charged by other physicians in the same geographic area. Basing an opinion on anecdotal testimony about the prices charged by one or two other doctors is not a reliable methodology. 

Courts have ruled that experts in medical billing do not need to be doctors. Instead, they need to be trained in the science of medical billing. They need to understand how to compare medical records to medical billings. They need to understand Current Procedural Terminology CPT codes to determine whether the billing reflects services that were actually provided. They need to understand the rules that govern those codes to make sure that a biller did not charge procedures using separate CPT codes when they should have been charged using a comprehensive CPT code. 

Medical billing experts gather sufficient facts to support their opinions about customary charges. They consult reliable databases that record the prices actually charged by physicians within a zip code for the same services or procedures that the injury victim received. They then use standardized methodologies to determine whether the charges in the medical billing fell within a range of reasonableness based on prices derived from the database.

Medical experts and medical billing experts have distinct but related roles to play in litigation. Medical billing experts do not offer medical opinions, just as medical experts do not offer opinions about the reasonableness of medical billings. Lawyers rely on both kinds of experts to recover full economic damages for injury victims.