How Personal Injury Defendants Use Medical Billing Review Experts

In the high-stakes arena of personal injury litigation, where a victim’s compensation hinges significantly on the extent of medical damages, a silent battle unfolds behind the scenes. While plaintiffs strive to substantiate their claims with comprehensive medical documentation, defendants are equally incentivized to scrutinize these claims for inaccuracies, inflated charges, or treatments unrelated to the incident. This is where medical billing review experts step into the spotlight, playing a crucial role in shaping the trajectory and outcome of personal injury cases.

The reality is that medical bills, often a cornerstone of damage claims, are rarely straightforward. A 2019 study revealed that a single day in a U.S. hospital could cost as much as \$5,220, a figure significantly higher than in many other developed countries. These costs, further complicated by intricate coding systems and varying pricing structures, can easily become a point of contention.

The Role of Medical Billing Review Experts

Medical billing review experts are professionals with specialized knowledge in healthcare billing practices, coding, and the reasonable costs of medical services. Their expertise is indispensable in personal injury cases, where the accuracy and fairness of medical bills can significantly impact the compensation awarded to the victim. Both sides, the plaintiff and the defendant, use reviewed medical documents as part of case-building, but in quite different ways.

Why Defendants Utilize Medical Billing Review Experts

Defendants in personal injury cases, typically represented by insurance companies and their attorneys, aim to minimize the financial impact of claims. They strategically employ medical billing review experts to achieve this goal through several key tactics:

Identifying Unnecessary Treatments: Defense experts meticulously examine the plaintiff’s medical records to pinpoint treatments or procedures that may be deemed unnecessary or unrelated to the claimed injuries. By challenging the necessity of certain treatments, the defense can argue for a reduction in the overall compensation owed.
Questioning Coding and Billing Practices: Medical billing is a complex process involving numerous codes that correspond to specific treatments and procedures. Defense experts scrutinize these codes to ensure accuracy and appropriateness. Any discrepancies, such as upcoding (using a code for a more expensive service than what was provided) or unbundling (charging separately for services that should be bundled under a single code), can be used to challenge the legitimacy of the plaintiff’s claims.
Assessing Alternative Explanations: In some instances, the defense may argue that the plaintiff’s injuries were pre-existing or that the treatments were not related to the accident. Medical billing experts help build these arguments by analyzing the timing and nature of the medical treatments in question, looking for inconsistencies or patterns that suggest alternative causes.
Ensuring Compliance with Standard Rates: Medical billing experts compare the billed amounts with standard rates for similar services in the area. This comparison ensures that the charges are reasonable and customary, which is essential for convincing insurance companies and the court of the validity of the claims.
Challenging the Reasonableness of Medical Bills: An award of medical expenses may be excessive if the award is based on medical billings that are inflated, mistaken, or otherwise unreasonable. It is a nearly universal rule that juries may only award reasonable medical expenses. While some jurisdictions presume the reasonableness of medical bills that have been paid, those jurisdictions typically permit defendants to challenge that presumption.

Tactics Employed by Medical Billing Review Experts

To effectively challenge medical bills, medical billing review experts employ a range of tactics, including:

Line-by-Line Review: Experts conduct a thorough, line-by-line analysis of medical bills, scrutinizing each charge for errors, duplicate entries, and inconsistencies.
Database Analysis: They utilize extensive databases of medical billing codes and pricing data to compare the billed charges with usual, customary, and reasonable (UCR) rates in the relevant geographic area.
Medical Record Comparison: Experts compare the services documented in medical records with the billing codes used to describe those services, identifying instances of upcoding or unbundling.
Expert Testimony: In many cases, medical billing review experts provide expert testimony in court, explaining their findings and opinions to the judge and jury in a clear and understandable manner.

The Daubert Standard

The admissibility of expert testimony, including that of medical billing review experts, is often subject to the Daubert Standard, a legal precedent that sets the criteria for determining whether scientific evidence is reliable and relevant. To meet the Daubert Standard, experts must demonstrate that their methodology is:

Testable: The methodology can be tested and subjected to peer review.
Generally Accepted: The methodology is generally accepted within the relevant scientific community.
Reliable: The methodology has a known error rate and is consistently applied.
Relevant: The methodology is relevant to the specific facts of the case.

The Impact on Personal Injury Cases

The use of medical billing review experts by defendants can have a significant impact on personal injury cases:

Reduced Settlements: By successfully challenging medical bills, defendants can lower the overall value of the case, leading to reduced settlement amounts.
Lower Jury Awards: If a case goes to trial, expert testimony from medical billing review experts can persuade juries to award lower damages for medical expenses.
Increased Scrutiny of Medical Claims: The involvement of medical billing review experts can encourage plaintiffs and their attorneys to be more diligent in documenting and justifying their medical expenses.

Advice

Maintain Detailed Records: Maintain comprehensive records of all medical treatments, bills, and related documentation. This information is essential for your medical billing expert to verify and justify the expenses.
Communicate Openly: Provide your attorney and medical billing expert with all relevant information about your medical treatments and expenses.
Seek Expert Guidance: Consult with a qualified personal injury attorney who can help you navigate the complexities of medical billing and protect your rights.

Conclusion

In the intricate landscape of personal injury litigation, medical billing review experts serve as essential players for defendants, ensuring that medical claims are accurate, reasonable, and directly related to the injuries sustained. By employing a range of tactics and leveraging their specialized knowledge, these experts can significantly influence the outcome of cases, protecting the interests of insurance companies and their clients.