A Comprehensive Guide to Medical Bill Reviews and Their Role in Injury Cases
When an injury case goes to litigation or settlement negotiations, the damages calculation often hinges on one central question: what are the true costs of medical care? For claims professionals, attorneys, and insurers, the largest share of damages almost always comes from medical bills. But bills are rarely straightforward.
On the surface, they list charges for services provided: a CT scan, a surgery, a round of physical therapy. Yet, behind those line items lies a complex system of coding, billing practices, and pricing structures that differ dramatically between providers, facilities, and regions. What looks like a “reasonable charge” to one party can be contested as inflated, duplicative, or unrelated by another.
That’s where a medical bill review becomes indispensable. A well-executed review can mean the difference between a defensible damages package and one that falls apart under scrutiny. In this article, we’ll explore in depth:
About the Expert
This guidance comes directly from April Pettengill, RN, CRRN, CDMS, CNLCP®, MSCC, CBIS, a Certified Nurse Life Care Planner and Director of Medico-legal Services. With decades of clinical, rehabilitation, and case management experience, April has extensive expertise in evaluating past medical costs, analyzing charges, and producing court-defensible reviews for injury and disability cases.
- Why reasonableness matters for damages
- The types of medical bills you’ll encounter
- The step-by-step review process
- Coding and charge analysis
- Benchmarks for evaluating charges
- The difference between charges and reimbursements
- What makes a bill review court-defensible
Why Reasonableness of Medical Bills Matters
Past medical damages are not just numbers on a page they are the backbone of any injury case. Courts and negotiating parties expect that bills presented are accurate, injury-related, and fair.
Without review, inflated or irrelevant charges can:
- Undermine the credibility of your case.
- Give opposing counsel ammunition to argue for reduced damages.
- Result in exclusions from recoverable damages.
On the other hand, undervaluing bills can leave money unclaimed, shortchanging the injured party. Reasonableness is about balance — ensuring bills are not only complete but also defensible when challenged.
For instance, if a $75,000 hospital stay includes unrelated procedures, that figure won’t stand unchallenged. A structured review can reduce disputes, clarify the scope of damages, and help ensure settlements reflect actual injury-related care.
Types of Medical Bills
Medical bills come in several standard formats, and recognizing them is the first step in knowing what you’re looking at:
1. HCFA 1500 (CMS-1500)
- The standard form for physicians and outpatient providers.
- Contains patient demographics, provider details, CPT codes (procedures), ICD-10 codes (diagnoses), and total charges.
- Example: A physical therapist billing for 12 sessions of gait training will list each session with corresponding CPT codes.
2. UB-04 (CMS-1450)
- Used by hospitals and facilities, particularly for inpatient care.
- Includes multiple services, dates, and departmental charges.
- Example: A physical therapist billing for 12 sessions of gait training will list each session with corresponding CPT codes.
3. Explanation of Benefits (EOB)
- Issued by insurers to patients, showing billed charges, allowed amounts, insurance payments, and patient responsibility.
- Helpful in seeing how a claim was processed but not adequate for litigation review since details are often missing.
Why itemization matters: A summary bill might read “Hospital stay: $25,000.” An itemized version breaks that into nursing care, IV supplies, imaging, and pharmacy charges. Without that breakdown, you cannot assess whether the charges align with accepted injury-related treatment.
Step 1: Identify the Accepted Injuries
Before you can review a bill, you must know what injuries are part of the claim. This step creates the boundary for what is in scope versus unrelated care.
- In workers’ compensation, this is defined by the adjuster.
- In liability cases, the accepted injuries are determined from medical records and expert input.
- Emergency care (ER visit, imaging, labs)
- Surgery (internal fixation, casting, or external fixation)
- Hospitalization and follow-ups
- Rehabilitation and therapy
Step 2: Match Bills to Medical Records
Medical records act as the compass for bill review. Every charge must be traceable back to documented treatment.
This is where coding systems become crucial:
- CPT Codes describe the service (e.g., CPT 73552 for X-ray of the femur).
- ICD-10 Codes describe the diagnosis (e.g., S72.92XA – unspecified fracture of left femur, initial encounter).
- Revenue Codes identify hospital departments (e.g., 360 for operating room services)
- List Item
Step 3: Review Charges for Appropriateness
The next step is analyzing whether charges are appropriate and justified:
- Do procedures make sense for the injury?
- Is there duplication (the same service billed more than once)?
- Do CPT codes match ICD-10 diagnoses?
Step 4: Compare Charges Against Reliable Benchmarks
Determining whether a charge is “reasonable” is one of the most critical and often most disputed steps in reviewing medical bills. How can anyone know if $1,200 for an MRI or $45 for a single Tylenol is appropriate? This step requires careful analysis and a methodical approach to ensure charges are defensible in court.
Method 1: Calling Providers
Some reviewers attempt to determine reasonableness by calling billing departments directly to ask about typical charges. While this approach can sometimes provide quick answers, it is generally unreliable. Responses often vary depending on who answers the phone, historic data is rarely available, and the results cannot be reproduced in court, making this method insufficient for litigation purposes.
Method 2: Facility Charge Masters
Hospitals publish Charge Masters, which are lists of published charges, often maintained to comply with price transparency regulations. While these lists can offer some insight, they have significant limitations. Charge Masters are frequently difficult to find on hospital websites, incomplete, or limited to the most common procedures. They may also reflect insurer-specific negotiated rates rather than the provider’s actual charges, and rarely provide historical data necessary for reviewing past claims.
Method 3: Databases (Preferred)
The gold standard for litigation is the use of medical charge databases. These databases compile millions of data points from across regions and provide percentile ranges, such as the 50th, 75th, and 90th percentiles, which are adjusted for geographic cost differences.
Their methodologies are scientifically grounded, reproducible, and widely accepted in court under Daubert standards. Because other experts can replicate the analysis and arrive at the same results, databases offer a reliable, defensible basis for determining whether a medical charge is reasonable.
Example 1: Why the Details of a Bill Matter
During the webinar, April Pettengill shared a case where a hospital provided what looked like a straightforward summary bill. It listed only a few lump-sum charges, such as daily room and board, but offered no insight into the specific services. On the surface, the $75,000 bill seemed reasonable for a multi-day admission.
Once the itemized bill was obtained, however, several issues became clear. The detailed statement showed charges for multiple X-rays unrelated to the accepted injury, routine supplies billed at excessive rates, and medications that were never tied to the patient’s treatment plan. Without that itemization, these inappropriate charges would have gone unnoticed.
By reviewing the bill line by line, comparing each charge to the medical record, and referencing benchmark databases, the inflated charges were removed. What originally appeared to be a $75,000 claim was reduced to a defensible $42,000, giving the legal team a reliable damages figure that could withstand scrutiny.
Example 2: Benchmarking Inpatient Room Charges
In another case, April reviewed a hospital bill that included inpatient room and board charges of more than $12,000 per night. For a five-day stay, that totaled over $60,000 just for the bed—not including surgery, imaging, or medications.
Rather than accept this figure at face value, the charges were compared against a recognized medical charge database for the same geographic region. The database showed that the reasonable charge for inpatient room and board in that area was closer to $5,000 per night.
By applying the benchmark standard, the billed amount was successfully challenged. What could have stood uncontested as an inflated $60,000 hospital stay was brought down to a figure that reflected true market reasonableness.
What Makes a Review Court-Defensible?
For a medical bill review to withstand scrutiny in litigation, it must go beyond surface-level analysis and demonstrate a clear, methodical approach. The process has to be reliable, meaning it is rooted in accepted medical and billing practices and supported by credible data sources. It must also be reproducible, so that another expert applying the same methodology could reasonably arrive at the same conclusions. This consistency is essential when testimony is challenged in court.
Equally important is the role of the reviewer. A court-defensible review should be conducted by a qualified professional—someone with the medical knowledge, coding expertise, and case management experience to interpret the charges and explain the findings clearly. When the methodology is sound, the data is trustworthy, and the expert is prepared to defend both the process and the conclusions, the review gains the credibility needed to hold up under cross-examination or judicial review.
Final Takeaway
- Clarify which charges are injury-related.
- Prevent inflated or unrelated costs from undermining damages.
- Provide data-backed support that holds up in negotiations and in court.
At Medical & Life Care Consulting Services, we specialize in creating clear, defensible medical bill reviews backed by decades of clinical and case management experience. Our methodology ensures that past medical damages are fair, accurate, and built to withstand scrutiny.
Complimentary Case Consultations
Have questions about medical charges in your case? Our team offers no-cost consultations to help you evaluate past medical bills and ensure your damages package is defensible. Schedule your consultation here.
