Position Summary
The Medical Bill Review Expert Witness provides independent, objective, and well-supported opinions concerning medical billing, healthcare reimbursement, adjustments, coding, billed charges, and the reasonable value/reasonable medical expenses/actual market value of healthcare medical goods and services. The position expert reviews medical bills, future cost estimates, including Life Care Plans with cost estimates, clinical records, payment information, billing affidavits, invoices, HCFA 1500’s, provider statements, and relevant reimbursement/payment data to evaluate whether charges are properly documented, accurately coded using the AMA CPT standards, and reasonable in relation to applicable healthcare payment methodologies and publicly available market information including benchmark values.
The Medical Bill Review Expert Witness prepares clear, articulate and defensible written reports, affidavits, declarations, demonstrative analyses, and other litigation-support materials. The expert may also provide testimony in depositions, hearings, arbitrations, or trials. The expert must be able to explain complex medical billing and reimbursement concepts clearly to attorneys, clients, judges, juries, and other individuals who may not have healthcare finance or medical coding experience.
Essential Duties and Responsibilities
The essential duties and responsibilities of this position include, but are not limited to, the following:
Medical Bill and Record Review
- Review itemized medical bills, claim forms, medical records, explanation of benefits documents, payment records, contractual information, and other case materials.
- Determine whether billed services are supported by the documentation contained in the clinical and billing records.
- Evaluate the accuracy and consistency of procedure codes, supply codes, revenue codes, modifiers, units, dates of service, and other billing information.
- Identify duplicate charges, unsupported charges, coding inconsistencies, unbundling, billing anomalies, and other issues that may affect the evaluation of medical expenses.
- Reconcile billing records with payment information, adjustments, write-offs, balances, and other available financial documentation.
Coding and Reimbursement Analysis
- Review AMA CPT standards, HCPCS, ICD-10-CM, revenue codes, and other relevant coding information.
- Analyze charges using appropriate reimbursement methodologies and information when relevant to the assignment.
- Evaluate charges and ratios of charges to applicable payment or reimbursement benchmarks associated with hospitals, physicians, chiropractors, nurse practitioners, physician assistants, ambulatory surgical centers, rehabilitation providers, pharmacies, durable medical equipment suppliers, ambulance providers, and other healthcare service categories.
- Evaluate future medical cost projections, surgical cost estimates, and life care plan amounts when included within the scope of the engagement.
Reasonable-Value Analysis
- Develop opinions concerning the reasonable value of medical services based on the facts of the case, the expert’s education and experience, and reliable analytical methods.
- Select and apply valuation methods appropriate to the services, providers, geographic area, dates of service, and available case information.
- Clearly distinguish billed charges from payments, reimbursement allowances, contractual adjustments, self-pay discounts, other adjustments, and other healthcare financial measures.
- Identify material assumptions, limitations, exclusions, and unavailable information that may affect the analysis.
- Maintain organized, reproducible documentation of the materials relied upon, work performed, methodologies used, calculations completed, findings reached, opinions expressed, and reports issued.
Expert Reports and Litigation Support
- Prepare clear, defensible expert reports and related litigation-support materials, including affidavits, declarations, rebuttal analyses, supplemental reports, exhibits, schedules, and demonstrative analyses. Each deliverable must describe the materials reviewed, methodologies applied, calculations performed, findings reached, and opinions formed.
- Present technical findings in language that attorneys, judges, juries, and other non-technical audiences can understand. The expert must be prepared to explain in layman’s terms how and why the billing charges, where indicated, are excessive and unreasonable.
- Review opposing expert reports, analyses, opinions, and supporting materials, and identify material differences in the data, assumptions, methodologies, calculations, and conclusions used in competing analyses.
- Assist retaining counsel in understanding medical billing, reimbursement, coding, and healthcare valuation issues within the proper scope of the expert engagement.
- Respond accurately and professionally to questions concerning opinions, methodologies, data sources, calculations, and supporting documentation.
- Meet court deadlines, discovery deadlines, report deadlines, and other requirements communicated by retaining counsel.
- Form and communicate truthful, objective, and professionally independent opinions based on the available evidence and reliable methods, including information that may not support the position of the retaining party.
- Testify only within areas supported by the expert’s knowledge, education, training, skill, and experience.
- Maintain consistency between the underlying analysis, written report, deposition testimony, and trial testimony.
- Make appropriate corrections or disclosures if a material error or omission is identified.
- Protect confidential case information, attorney work product, personally identifiable information, and protected health information (PHI) per the HIPAA Privacy Rule.
- Avoid conflicts of interest and promptly disclose any actual or potential conflict.
- Maintain professional conduct and comply with all applicable company policies, confidentiality requirements, and engagement terms.
Professional Development and Quality
- Remain current on medical coding conventions set forth by the American Medical Association (AMA) and other recognized entities, healthcare reimbursement practices, payment methodologies, billing developments, and professional standards relevant to assigned matters.
- Maintain applicable professional credentials and complete required continuing education.
- Participate in internal quality-control and peer-review processes without compromising the expert’s independent judgment.
- Contribute to the development and refinement of report templates, research protocols, valuation procedures, and quality standards.
- Perform additional duties and case-related projects as assigned, provided those duties remain consistent with the expert’s qualifications and professional responsibilities.
Education
- Bachelor’s degree in healthcare administration, healthcare finance, accounting, business administration, economics, nursing, health information management, or a related field.
- An equivalent combination of relevant education, professional credentials, and substantial healthcare reimbursement experience may be considered.
Professional Experience
- Substantial professional experience in medical bill review, healthcare reimbursement, medical coding or auditing, revenue cycle management, healthcare finance, claims administration, healthcare compliance, payment analysis, or healthcare consulting.
- Demonstrated professional experience reviewing medical bills and related clinical or financial documentation, conducting comparative charge, payment, adjustment, or reimbursement analyses, and preparing written reports that explain healthcare financial findings.
- Working knowledge of healthcare claims processing, common reimbursement methodologies, CPT, HCPCS, ICD-10-CM, revenue codes, modifiers, billing conventions, and payment models across multiple healthcare service settings, including self-pay and private-pay arrangements.
- Ability to organize and analyze large volumes of billing, clinical, reimbursement, and payment information.
- Ability to explain the valuation of healthcare charges clearly to a non-technical audience.
Preferred Qualifications
- Prior experience serving as a medical bill review expert witness or consulting expert, including preparing expert reports, affidavits, declarations, or rebuttal analyses and providing deposition, hearing, arbitration, or trial testimony.
- Experience evaluating billing charges, UCR, past medical expenses, future medical costs, surgical cost estimates, or life care plan cost estimates.
- Familiarity with Texas healthcare billing and reimbursement matters and litigation involving the reasonableness of medical charges.
- Experience supporting attorneys in personal injury, insurance, workers’ compensation, healthcare, or other medical-expense disputes.
- Advanced degree or additional professional education in healthcare finance, coding, auditing, economics, accounting, or a related discipline.
The expert must have appropriate knowledge, skill, experience, training, or education for the particular opinions to be offered. Please see Federal Rule of Evidence 702.
Knowledge, Skills, and Abilities
The successful expert witness candidate must demonstrate the following:
- Advanced knowledge of medical billing, coding, claims processing, and healthcare reimbursement, including the AMA’s adoption of RVRBS.
- Knowledge of healthcare charge structures, payment mechanisms, contractual adjustments, and reimbursement benchmarks.
- Ability to select, apply, and explain reliable medical-charge valuation methods.
- Ability to distinguish among charges, payments, allowed amounts, contractual rates, adjustments, write-offs, and outstanding balances.
- Ability to assess the relevance, reliability, strengths, and limitations of healthcare financial data.
- Strong quantitative, analytical, research, problem-solving, written communication, technical report-writing, verbal communication, and presentation skills.
- Ability to respond professionally and accurately during questioning or cross-examination.
- Ability to remain objective and independent regardless of the identity of the retaining party.
- Ability to identify and disclose assumptions, limitations, missing information, and alternative interpretations.
- Excellent attention to detail and commitment to accuracy.
- Effective organization, deadline management, and case-file management skills.
- Proficiency with standard office, spreadsheet, document-management, and analytical software.
- Ability to handle confidential information with discretion.
Demonstrates sound judgment, clear written and oral communication, attention to detail, credibility, research proficiency, time management, confidentiality, adaptability, and professional independence when completing expert assignments.
Professional Independence
Forms objective opinions based on the available evidence, reliable methods, and professional expertise rather than the desired outcome of a retaining party.
Analytical Judgment
Evaluates complex billing, coding, clinical, payment, and reimbursement information using logical and supportable reasoning.
Written Communication
Produces reports that are organized, accurate, understandable, and sufficiently detailed to explain the basis of the expert’s analysis and opinions.
Oral Communication
Explains technical healthcare financial concepts clearly and responds directly and professionally during testimony.
Attention to Detail
Verifies data, calculations, citations, schedules, and supporting records before issuing an opinion or report.
Credibility
Demonstrates consistency, preparation, objectivity, professionalism, and respect for the limits of the expert’s expertise.
Research
Identifies and evaluates relevant reimbursement information, billing standards, coding materials, payment data, and industry resources.
Time Management
Plans and completes work in accordance with litigation schedules and applicable deadlines.
Confidentiality
Protects case information, medical information, client information, and attorney work product.
Adaptability
Responds effectively to new evidence, supplemental records, revised assumptions, scheduling changes, and evolving case requirements.
Texas Expert-Witness Expectations
The Medical Bill Review Expert Witness must be able to demonstrate that the opinions offered in a Texas matter fall within the expert’s actual qualifications and area of expertise. The expert must use methods that can be clearly explained, consistently applied, and supported by the information reviewed.
The expert is expected to:
- Identify the specific subject areas in which the expert is qualified to offer opinions.
- Explain how the expert’s education, training, credentials, and experience relate to those opinions.
- Identify the facts, records, data, and assumptions considered; explain the methodology used to reach each material opinion; and demonstrate how the methodology was applied to the facts of the case.
- Acknowledge material limitations, missing records, and contrary information.
- Avoid legal conclusions or clinical opinions outside the expert’s qualifications.
- Cooperate with retaining counsel regarding applicable disclosure, report, affidavit, and testimony requirements while preserving professional independence.
Important: This section describes job expectations and is not intended to provide a legal determination that an individual is qualified to testify in a particular case. Qualification and admissibility depend on the expert’s credentials, the opinions offered, the underlying methodology, the facts of the matter, and the applicable legal requirements. Texas counsel should review matter-specific language before the expert signs an affidavit, declaration, or report.
Work Environment
This position primarily operates in a professional office or remote-office environment. The role routinely requires the use of computers, telephones, videoconferencing systems, document-management platforms, spreadsheets, and standard office equipment.
The position involves prolonged periods of reviewing electronic or paper records, analyzing data, preparing reports, and participating in meetings or testimony.
Physical Requirements
The physical requirements described below are representative of those ordinarily associated with the position:
- Ability to remain in a stationary position for extended periods.
- Ability to communicate effectively by telephone, videoconference, deposition, hearing, and trial.
- Ability to operate a computer and other standard office equipment.
- Ability to review electronic and printed records.
- Ability to occasionally move or carry office materials weighing up to ten pounds.
Reasonable accommodations may be made to enable qualified individuals to perform the essential functions of the position.
Travel
Travel of up to 10 percent may be required for depositions, hearings, trials, client meetings, or other case-related activities.
Equal Employment Opportunity
Medical Equation is an equal opportunity employer committed to maintaining an inclusive workplace. Employment decisions are made without unlawful discrimination on the basis of any status protected by applicable federal, state, or local law.
Disclaimer:
This job description is intended to describe the general nature and level of work performed by an individual assigned to this position. It does not contain a comprehensive listing of every duty, responsibility, qualification, or working condition associated with the position.
Management may revise the responsibilities of the position based on business and operational needs. Nothing in this job description alters the expert’s obligation to maintain independent professional judgment when conducting an analysis, preparing an opinion, or providing testimony.
This job description is not a contract of employment and does not guarantee assignment to any particular matter or acceptance of any opinion by a court or other decision-maker.
