Most states follow the rule that a plaintiff can recover more than what an insurer pays when it comes to medical bills paid related to the incident. However, a growing number of states are beginning to consider the practical application of rules limiting such awards to those payments actually made by the insurer. In Haygood v. Escabedo, 2011 Tex. LEXIS 514, the Texas Supreme Court held that TEX. CIV. PRAC. & REM. Code § 41.0105 precludes a plaintiff from introducing evidence of medical bills that had been billed but for which plaintiff was not obligated to pay. The Court reasoned that evidence of charges which will never actually be paid to a health care provider are irrelevant to the issue of damages and thus are not admissible.

For cases involving Medicare beneficiaries, this decision is an important one. First, it can be used as leverage to require the discovery of Medicare’s conditional payment letter. No longer will the collateral source rule serve as a defense. Second, what Medicare pays is far less than what is billed by the health care provider. The providers care are not authorized to balance bill the beneficiary in a liability claim under 42 C.F.R. §411.31. Therefore, what Medicare pays can be the only amount that is relevant under this new decision.

Franco Signor LLC specializes in indentifying conditional payments owed by Medicare. We look forward to working with you to identify the actual damages involved in a claim in order to achieve what is the fair and appropriate value for the loss. Leverage our expertise as we provide you with winning strategies to reduce exposure.


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