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If there are no collateral source payments – and therefore no post-verdict collateral source reduction available for the healthcare provider’s inflated bills – it is critical that the defendant be able to challenge the reasonableness of the provider’s bills. Also, permitting a plaintiff to board the full amount of the charges without permitting the defendants to challenge the reasonableness of the bills with direct evidence from the healthcare provider will likely result in a windfall for the plaintiff at the defendant’s expense after the plaintiff negotiates down the inflated bill post trial.
Below are a few examples comparing the amounts charged by a healthcare provider versus the amounts routinely accepted as full payment by a majority of the patients.
Procedure Code
22551 for Orthopedic #1 22551 for Orthopedic #2 63075 for Orthopedic #1 22845 for Orthopedic #1 22551 for Surgery Center 22552 for Surgery Center 20936 for Surgery Center
Amount Charged
Average Reimbursement
Average % of Charged Amount Paid
$1,491.68 $2,951.95 $1,466.93 $924.86 $4,118.93 $2,072.32 $2,065.43
$18,610.00
$1,491.68
$15,220.84
$2,951.95
$35,000.00
$1,466.93
$6,277.05
$924.86
$26,364.90
$4,118.93
$17,385.87
$2,072.32
$15,234.10
$2,065.43
In addition to determining the average amount accepted for a particular CPT code, discovery will reveal the total amount of money charged, accepted and adjusted for particular procedures. In a particular case, we discovered that a local orthopedic surgeon billed $6,499,300.75 for procedure code 22551 during a three- year period. Of that amount, the physician’s practice received payments of $1,263,437.02 and adjusted/ reduced $4,359,252.41. For procedure code 22851, the same orthopedic surgeon billed $3,683,427.50, collected $486,142.72 and adjusted/reduced $2,442,928.67. Similar information can also be obtained from surgery centers and hospitals. We have obtained discovery that revealed that a local surgery center billed $5,773,734.00 for procedure code 20936 during a three year period. Of that amount, the surgery center received $782,801.10 as payment. There is a treasure trove of information that is discoverable with respect to the true reasonable value of a healthcare providers’ medical charges.
The billing and payment history of a plaintiff’s medical providers is relevant and discoverable. Defendants have an absolute right to refute, challenge and contest the inflated charges. In Columbia Hosp. Ltd.
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