Medical Bill Audits

Expert Testimony to Determine Reasonable Value of Medical Services

Generally in personal injury cases, a plaintiff must show that the medical services received were: (1) attributable to the accident or causative event; (2) that they were necessary; and (3) that the charges for such services were reasonable, justified, actually incurred, accurate and do not contain billing errors.

The first two issues are addressed in either a Medical Record Review or Independent Medical Evaluation (IME).

The third issue constitutes the primary purpose for a medical billing analysis.

The Ohio Supreme Court has ruled on this subject in several instances. In its 2006 decision in Robinson v Bates, the Ohio Supreme Court held that, for trial purposes in bodily injury cases, an original medical bill in the amount accepted as full payment of the bill is admissible to prove the reasonableness and necessity of charges for medical and hospital care. Frequently, the amount paid by a health insurer for a medical bill is only a small portion of the total medical bill. The ruling in Robinson v. Bates has allowed insurance defense counsels to argue, usually successfully, to the jury, that the reasonable and necessary amount of the medical bills is the amount paid by the health insurance company, not the amount of the total bill. This decision was validated by the Ohio Supreme Court in 2009 in Jacques v. Manton.

The decision in Robinson v Bates has served as a model for other jurisdictions across the country grappling with the issue of permitting juries to consider reductions, or “write offs,” of medical bills in personal injury actions when determining the reasonable value of medical services.

However, on March 21, 2012, in Moretz v. Muakkassa, the Ninth Appellate District placed limitations on Robinson v. Bates and Jacques v. Manton and held that expert testimony is required to present evidence to the jury of the reasonable value of medical services. It no longer is good enough, at least in the Ninth Appellate District, for defendants to offer evidence of write-offs in hopes that juries will determine that the reasonable value of the medical services was actually equal to the amount charged by the health care provider minus the amount written off by the health care provider after it had received partial payment of the bill from the health insurer.

While the Ninth Appellate District acknowledged that the bills themselves create a “rebuttable presumption” being reasonable under R.C. §2317.421, it held that there is no presumption or shortcut available to allow evidence of medical bills write-offs to be introduced without a proper foundation with expert testimony.

This decision is the subject of an appeal currently before the Supreme Court of Ohio. Although the majority if other jurisdictions around the country do not require expert testimony for the determination of reasonable value of medical services; several other jurisdictions have adopted this perspective.