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Insights SPRING2021
The first step to obtain billing information in your case is to review the plaintiff ’s medical records in your case with respect to the CPT codes7 for each procedure performed. The permissible discovery obtainable from medical providers is information regarding the payments, discounts and adjustments by the healthcare providers for other patients who received the same medical care per the documented CPT codes. For example, an anterior cervical discectomy and fusion surgery at two levels typically has CPT codes 22551, 22552, 22845 and 22851 for the surgeon and 22551, 22552 and 20935 for the surgery center. In cases with Letters of Protection, you can expect the surgeon’s charges to be in excess of $75,000, while the surgery’s center’s charges will be approximately $100,000.00. Once you obtain your plaintiff’s medical bills, defense counsel needs to issue direct discovery to the healthcare providers to obtain what the provider accepts as full payment from other patients8 who received care documented by the same CPT codes. For the above- noted surgeon CPT codes, the subpoena, followed by a corporate representative deposition, should seek the following:
1. Copies of medical charges billed, payments made and discounts/adjustments made to patients who received the same medical care per the CPT codes received by (plaintiff) for a three-year period from January 1, 2016 through January 1 2019,9for patients with the following CPT codes as listed on your billing records for (your patient): 22551, 22552, 22845 and 22851 (for physicians, assistants, nurses, practitioners), with all patient identifying information redacted.
2. Summaries, analysis and spreadsheets for charges billed, payments made and discounts/ adjustments made to patients who received the same medical care per the CPT codes received by (plaintiff ) for a three-year period from January 1, 2016 through January 1, 2019 for patients with the following CPT codes as listed on your billing records for (your patient): 22551, 22552, 22845 and 22851.
3. Documentation, including agreements, rates and pricing lists or guidelines that reflect the amount that your medical practice would accept from Medicare for coded medical procedures 22551, 22552, 22845 and 22851.
4. Documentation, including agreements, rates and pricing lists or guidelines that reflect the amount that your medical practice would accept from Aetna, United Health, Humana, Blue Cross-Blue Shield and Cigna health insures for coded medical procedures 22551, 22552, 22845 and 22851.
Plaintiffs and the medical providers will object to discovery of this information, claiming relevancy,
confidentiality and privilege. However, this information is relevant, discoverable and eventually admissible without revealing collateral sources or health insurance. The reason the healthcare providers and plaintiff attorneys do not want this information exposed is because the information will uncover that when comparing a majority of the healthcare provider’s patients that undergo the same medical procedure, the amount accepted as full payment is exponentially less than what is charged. In other words, for a majority of the provider’s patients that receive the same medical care and procedure (per the CPT code) as the plaintiff, the amount accepted as fully payment for the procedure is far less than the sticker price charged in the case.
The law is clear, the prices charged to other patients, and the amounts received from them [differ], and this difference may offer some insight into the value of the actual services provided.”10 The rates that hospitals charge do not always accurately reflect the value of the services, especially when the hospital routinely accepts much less for them.11 Evidence that the hospital accepts significantly less for services provided to patients with insurance and government benefits suggests that the value of the services charged to plaintiff may be significantly less than what [the healthcare providers] asked her to pay.12