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Plaintiffs in personal injury cases have the right to claim full compensation for all medical expenses incurred due to the injurious incident. It’s not uncommon for insurance companies to challenge the plaintiff’s medical bills, especially in high-value claims or those involving estimations for future medical services.
The defendant’s (the at-fault party) attorney may challenge the billing amounts as part of a negotiation strategy or in their argument before a jury. It’s common for both the plaintiff and the defendant to have an expert witness review the plaintiff’s medical records as part of the case-building strategy to prove or disprove causation and determine if the medical bills support the amount requested in medical damages.
Our Fort Lauderdale medical malpractice attorney often contracts with medical billing experts in our role as plaintiffs’ attorneys, for several reasons.
What does a medical billing review expert do?
Medical billing review is a line-by-line analysis of the patient’s medical bills. Medical billing experts review the billing codes on each bill, checking for duplicate charges, typos, or other errors that may have inflated the billing.
Cases in which the plaintiff requires multiple procedures, a lengthy hospital stay, or accommodations in a skilled nursing facility may have pages and pages of medical bills, which often require expert review to ensure that the plaintiff received all services and medications.
By comparing customary charges and accepted billing practices with the plaintiff’s records, these experts in personal injury can help better calculate the true value of the plaintiff’s medical damages.
Both sides use the reviewed medical documents as part of case-building, but in quite different ways.
How plaintiffs in personal injury claims use medical billing experts
Personal injury plaintiffs seek recovery of all out-of-pocket expenses incurred due to an accident caused by the defendant’s negligence. Medical expenses are considered special damages and include both post-accident care and any follow-up or ongoing care the plaintiff may need in the future.
For example, if the plaintiff requires multiple surgeries, spread out over months, their claim may include the cost of those surgeries. Or, the case may involve a plaintiff suffering from a chronic medical condition (like you would see in a dangerous drug or toxic exposure tort) who requires regular medical treatments. These cases, and similar ones, involve future medical damages.
Plaintiffs can only recover medical damages for procedures deemed reasonable and medically necessary for the treatment of injuries caused in the accident. An expert witness, like a doctor or surgeon, can testify whether the procedures were medically necessary; a medical billing expert testifies whether the cost of the procedures was reasonable.
A physician’s area of expertise typically covers whether certain treatments were necessary, but their expertise usually doesn’t extend to what other healthcare providers and facilities charge for similar procedures. A medical billing expert’s testimony covers what the customary cost of each service is, and what other providers charge for similar services.
The plaintiff’s general damages, non-material damages like pain and suffering, and loss of quality of life, are typically based on the total value of their special damages. So, it’s in the plaintiff’s best interest to argue for the highest possible amount of material damages.
How defendants use medical billing expert testimony
The defense’s goal is to minimize any recovery they may owe the plaintiff. Juries may only award damages for reasonable medical expenses, but the plaintiff’s idea of reasonable and the defendant’s are usually widely different.
The defense can challenge the medical bills presented for compensation by having a medical billing expert review them and indicate which expenses are unreasonable, inaccurate, or inflated.
Duplicate billings, a service that was billed but not performed, typos that resulted in larger bills, or “upcoding,” entering a CPT code for a more expensive service than the one provided, are common errors a medical billing expert can spot.
Medical bills may also be ruled unreasonable if they exceed the usual, customary, and reasonable (UCR) rate for a billed service. If the plaintiff’s bill reflects a higher charge than the physician usually charges patients for the same procedure, it is not considered the “usual” charge. If the charge is higher than that of other practitioners in the area, it may be contested as “not customary.” A defense lawyer can use testimony like this to challenge the plaintiff’s stated medical damages.
Both plaintiff’s personal injury lawyers and defense attorneys may use medical billing experts, but each one applies the information differently. Your medical records will play a vital role in your case, so be sure to save all documentation and give copies to your personal injury lawyer.
Get help reviewing your medical damages
Medical billing disputes can make or break a personal injury claim. If you’re facing pushback on your medical expenses, our team can help. At Lytal, Reiter, Smith, Ivey & Fronrath, we work with trusted medical billing experts to support our clients and fight back against unfair denials. Call us today at (561) 655-1990 for a free consultation.