Can RNs give expert testimony as to whether bills are reasonable?
ISSUE: Is expert testimony as to the reasonableness of medical bills incurred by a patient who has sustained personal injuries admissible in evidence?
CASE FACTS: Twyman and Terry Bowling brought suit against their own Automobile Liability Insurance Company. State Farm Automobile Insurance Company (State Farm), under the Uninsured Motorist (UM) provision of their own policy after they were involved in a motor vehicle accident in which the owner and operator of the vehicle which was allegedly responsible for the accident and their resulting injuries. During the course of a jury trial, State Farm stood in the shoes of the uninsured owner and operator. The case proceeded to trial before a jury, after which the jury awarded the Bowlings $944,154.50 for damages sustained by them. The trial court reduced the judgment to the policy limits of $100,000 in accordance with the terms of the insurance policy. State Farms's witness list indicated that Debra Pacha had been retained by State Farm as an expert witness to testify as to "the reasonableness of charges for medical treatment rendered to" Mr. Bowling. She testified that she compared the bills to the medical treatment records and found "extreme abuse in regard to the coding, billing[,] and State Farm as an expert witness to testify as to "the reasonableness of the medical bills incurred by the plaintiff and documentation "of four of Mr. Bowlings' main medical care providers. She further testified that as to those four providers, "there is absolutely nothing within that documentation that is supportive or representative of any of the billed procedures that I have reviewed. M Her report also indicated that she reviewed $278,000 in medical bills and found that Sill,000 in charges did not have any supporting medical codes. The Bowlings filed a motion to exclude Ms. Pacha's testimony, arguing that it would not assist the jury in determining whether Mr. Bowling's bills were reasonable, that Ms. Pacha was not qualified to render an opinion as to the reasonableness of the bills, and that in her deposition, she failed to give any opinion as to the reasonableness of the bills. Prior to trial the trial court granted the Bowlings' motion by written order, finding that "the testimony of the witness will not assist the jury in determining whether Mr. Bowlings' Medical bills are reasonable" and that Ms. Pacha was not ""qualified to render an opinion as to the reasonableness of the reasonableness of the medical bills. State farm contended that the trial court had erred in excluding the testimony regading reasonableness of bills.
COURT'S OPINION: The Court of Appeals of Florida reversed the judgment entered by the trial court and remanded the case back to it on the issue of damages only. The court held, inter alia, that the trial judge erred in excluding the expert testimony of Debra Pacha. The court noted that State Farm's expert witness was a former x-ray technician who became licensed in the forensic examination of medical record coding and billing. Further, the court found that Ms. Pacha had extensive experience and expertise in reviewing medical records for improper coding and charges to medicare and medicaid. In addition, the feet that at least two of the Bowlings medical providers admitted that they had made errors in charging for items that should not have been billed.
LEGAL COMMENTARY: Nurses who have had experience in determining whether billing codes and charges are proper may be, in some cases, accepted as expert witnesses, depending upon the length of time they have performed such services as well as whether they have been recognized as expert witnesses as to proper and improper coding for medical procedures. Experience has revealed that more often than we would like to see, so-called experts in medical coding have been found to have used the wrong codes, while acting in good faith. So too, any number of employees of health insurers as well as employees of government agencies have, while acting in good faith, approved claims improperly coded as well as denied claims, which were properly coded and should have been approved without question of any delay. Nurses who have had the requesite experience in coding often feel that they might have future career possibilities by virtue of their knowledge and experience in coding. Following the age-old adage that the grass always appears greener in the neighbor's yard, nurses contemplating changes in their careers should look twice before they leap! It is interesting to note that a separate opinion was filed by one judge who concurred with the majority in part and dissented from the majority opinion in part. In the dissenting portion of his opinion, the dissenting judge expressed his concern that given the majority's broad languaged, he was concerned that the majority opinion would be interpreted as a blanket authoriziatioon for the regular introduction of billing code experts at trial to contest the reasonableness of injuries.
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|Title Annotation:||Nursing Law Case of the Month|
|Publication:||Nursing Law's Regan Report|
|Date:||Feb 1, 2012|
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