Authors
For several years RPC has prepared reports and affidavits on reasonable charges for past medical expenses based on usual, customary, and reasonable charges in a medical market at the 75th or 80th percentile (UCR80). Our work has often been in response to a Section 18.001 filed by personal injury plaintiffs, or in assisting plaintiffs with resolving medical liens.
Recent decisions by the Supreme Court of Texas (SCOT) have held that a defendant in a personal injury case may recover only the reasonable value of past medical expenses. The SCOT has also held that a healthcare provider’s charges are sometimes not a reliable indicator of the reasonable value of the services.
Where a provider has agreed to negotiated rates with health plans, or when the plaintiff has access to negotiated rates through insurance, these negotiated rates are reference points for the reasonable value of the services in that specific case. SCOT decisions now grant defendants reasonable discovery from plaintiffs and plaintiff’s healthcare providers to learn the negotiated rates. RPC can assist defense counsel in framing discovery requests within SCOT parameters.
For cases where information on negotiated rates is lacking, RPC has developed a method for quantifying the range of reasonable values for healthcare goods and services based on research on government data and payment practices of health plans. As a general rule, we find the range of reasonable value of services is from 100 percent of the Medicare rate to the UCR80 charge. A reasonable point estimate of value, absent data on negotiated rates, is 200 percent of the Medicare rate.
RPC has prepared a sample report explaining how we determine maximum reasonable charges for past medical services and how we determine the range of reasonable value of past medical services. The sample report is available here. For questions about the report or about RPC’s services analyzing medical expenses, please contact Ron Luke, JD, PhD (rluke@rpcconsulting.com, 512.371.8166) or Brian Piper, PhD (bpiper@rpcconsulting.com, 512.371.8014)