When Is a Medical Bill Review Report Needed?

In personal injury or accident-related cases, disputes often arise regarding the reasonable value of medical care provided. When this happens, a Bill Review Report or Past Medical Bill Analysis can help clarify what charges are appropriate and whether they align with industry standards.

What Is a Bill Review?

A bill review is a structured analysis of medical billing to assess the accuracy, appropriateness, and reasonable value of the charges. There are two common levels of review: Basic and Comprehensive.

Basic Bill Review

A Basic Bill Review involves evaluating the submitted bills to determine if the charges align with usual for the same procedures in the same location on the same date. This is typically done using benchmark databases such as:

  • Context 4 Healthcare
  • Veterans Affairs fee schedules
  • Other regional or national pricing databases

Key Assumptions:

  • All treatment is related to the accident or incident.
  • All billing codes are correctly assigned and appropriate.

This type of review does not include an analysis of medical records. It’s most useful for straightforward cases where the relationship between the treatment and the incident is not in dispute.

Comprehensive Bill Review

A Comprehensive Bill Review goes much deeper. It includes:

  1. Medical Record Comparison – Each charge is reviewed against the corresponding medical record to confirm:
    • It was related to the accident or incident.
    • It was not solely related to pre-existing conditions.
  2. Billing Code Validation – Reviewers verify that:
    • The documentation supports each billed code.
    • The code was current, valid at the time of billing, and appropriate for the services provided.
    • The code was not billed inappropriately in combination with other codes (e.g., unbundling or upcoding).
  3. Fair Market Value Determination – Each charge is compared against benchmark pricing to determine what is reasonable for that location and date of service.

Why This Matters in Legal Claims

In litigation, a plaintiff cannot claim more than the actual value of the medical services rendered. Therefore, after a bill review, the final allowable amount becomes:

The lesser of:
• The provider’s original charge
• The independently researched reasonable value

This ensures that any compensation claimed for medical costs is justified, defensible, and fair—to all parties involved.

Trusted Expertise in Medical Bill Review

This process requires experience, clinical knowledge, and a deep understanding of billing practices. Dawn Cook, a licensed Registered Nurse with over 46 years of clinical experience, brings exactly that. As a Certified Life Care Planner (CLCP) and Certified Nurse Life Care Planner (CNLCP), Dawn has completed:

  • Over 1,000 life care plans
  • More than 600 past medical bill reviews
  • Reports in 39 states and the District of Columbia
  • Expert testimony in over 250 cases, including 30 trials

Her detailed and defensible analyses have been trusted by both plaintiff and defense attorneys, and she has testified in both state and federal courts, as well as tribal court.

Need Help with a Medical Bill Review?
Whether you need a straightforward bill assessment or a comprehensive review backed by decades of clinical and forensic expertise, Dawn Cook provides reliable, research-based support for your case.

📩 Contact Dawn Cook today to learn more or schedule a consultation.