Plaintiff Michael Swartzendruber claimed that Defendants United Healthcare Insurance Company and United Healthcare of the Mid-Atlantic, Inc. (collectively “United”), and Defendants Sentara RMH Medical Center and RMH Medical Group, LLC (collectively “Sentara”) overcharged him for hospital services and/or by making misrepresentations about the charges for his blood tests.
On each occasion, Swartzendruber’s blood was drawn at a Sentara satellite outpatient location and tested at Sentara’s main hospital location. Sentara billed, and United processed and reimbursed, charges for medical services based on rates associated with the main hospital location as opposed to rates of certain providers operating at the satellites.
Plaintiff filed a motion to exclude the expert testimony of Defendants’ expert, Kristina Kahan. Kahan was retained to opine on whether or not the health insurance claims at issue in this case were properly billed.
Medical Coding Expert Witness
Kristina B. Kahan is a Registered Nurse, Certified Professional Coder, and senior managing director at Ankura Consulting with decades of clinical, compliance, and coding experience in the healthcare industry.
She holds multiple coding certifications: Certified Professional Coder (“CPC”), Certified Outpatient Coder (“COC”), and Certified Risk Adjustment Coder (“CRC”).
Discussion by the Court
To begin with, Plaintiff challenged the relevancy and helpfulness of Kahan’s opinions, and disputes that Kahan has offered a sufficient basis on which to offer her opinions.
a) Basis for Opinions
In her report, Kahan concluded that Sentara properly submitted claims for the services at issue in this case and that United properly adjudicated the claims it received from Sentara.
Specifically, Kahan concluded that Sentara appropriately billed the services rendered as originating from Sentara RMH Medical Center because the services were “performed at off-campus locations of RMH Medical Center and the blood testing was performed at RMH Medical Center’s main hospital location” and thus constituted “facility services.”
Kahan concluded that Sentara properly billed and United properly adjudicated the claims. In making these conclusions, Kahan evaluated Sentara RMH Medical Center’s hospital certification and Medicare Provider Enrollment, Chain, and Ownership System information. As a result, the Court found that Kahan has developed sufficient bases on which to support her opinions.
b) Relevancy and Helpfulness
Defendants asserted that Kahan’s report addressed material aspects of the case—whether Sentara appropriately submitted the claims and whether United appropriately adjudicated them.
However, Plaintiff argued that Kahan’s report is not helpful to the Court because Kahan offered no testimony that is helpful or necessary for the Court to interpret the contract at issue.
The Court found that the Kahan Report presented relevant and helpful evidence as it served to assist the Court in understanding the healthcare claims submission and adjudication processes, including the relevant regulations governing these processes, such that the Court is better equipped to address the issues in dispute in this case.
Held
The Court denied the Plaintiff’s motion to exclude Defendants’ expert Kristina B. Kahan.
Key Takeaway:
Basically, the parties are correct that the Court can read and interpret the contracts at issue, and the Kahan Report does not improperly delve into the world of contract interpretation. Thus, the Court may consider the Kahan Report for its value in understanding the broader environment of the instant case.
Case Details:
| Case Caption: | Swartzendruber V. Sentara RMH Medical Center Et Al |
| Docket Number: | 5:22cv55 |
| Court Name: | United States District Court, Virginia Western |
| Order Date: | September 16, 2025 |
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