Should an RN with extensive background in medical coding and billing be permitted to testify that only 30% of short-stay admission had adequate documentation to support the in-patient level of care billed to Medicare?

A Florida court said yes and rejected the attempt to exclude her testimony.

The court, in US v. Halifax Hospital Medical Center, Dist. Court, MD Florida 2014 stated:

Schmor, a registered nurse, has 12 years’ worth of experience in nursing, more than 6 years’ worth of experience in medical coding and billing, and numerous certifications in these fields. Yet Defendants attack her credentials, primarily by asserting that a nurse (and presumably anyone else) “is not clinically qualified to offer opinions second-guessing the judgment of the physicians who concluded it was medically necessary to admit the patient. (Doc. 430 at 4). In other words, according to the Defendants’ logic, the admitting physician’s decision to admit a patient is unassailable. If this were true, the medical necessity of inpatient admissions would be insulated from legal review and sanction, which is clearly not the case.[3] Thus, Schmor is qualified to conduct a medical necessity review of short-stay admissions at Halifax and opine as to the error rate observed.

In conducting her review, Schmor used recognized industry criteria, including Milliman Care Guidelines, McKesson’s InterQual Criteria, and clinical review judgment. The Defendants do not attack the reliability of Schmor’s methodology per se, but rather the statistical sample used by her for the review. That sample was drawn by another of Relator’s experts, Douglas Steinley, and the validity of the method by which he did so will be addressed in a separate order. The purported flaws in the resulting sample noted by the Defendants go to the weight of the evidence, not its admissibility. Accordingly, the method used by Schmor to conduct her review satisfies the reliability prong of Rule 702.

Finally, Schmor’s testimony will clearly assist the jury. Medicare billing is a complicated subject, beyond the knowledge or understanding of the average lay person, and the Defendants do not suggest otherwise. It is, therefore,

ORDERED that the Motion to Strike the Expert Report of Jessica Schmor and to Exclude or Limit her Testimony (Doc. 430) is DENIED.


NOTE: The court followed the rule that medical necessity reviews do not typically require a physician.