Billing Opinion Reliability Score 100: A Structured Framework for Billing and Medicolegal Expert Reliability

Area of Science:

• Medical Law and Ethics
• Health Economics
• Forensic Accounting

Background:

• Expert opinions in medical billing, coding, and reimbursement disputes often lack consistent transparency and methodological rigor.
• Existing legal processes may assess expert reliability but lack a uniform rubric for evaluating internal methodological quality across dispute types.
• This variability impacts the fairness and accuracy of decisions in medicolegal and administrative settings, including No Surprises Act Independent Dispute Resolution (NSA/IDR).

Purpose of the Study:

• To introduce the Billing Opinion Reliability Score 100 (BORS100), a conceptual framework designed to standardize the assessment of expert opinions in medical billing and reimbursement.
• To provide a structured rubric for evaluating the transparency, evidentiary support, and methodological discipline of expert opinions relevant to medicolegal and administrative disputes.

Main Methods:

• BORS100 was developed through a three-step process involving literature review, extraction of reliability limitations, and consolidation into seven scoring domains.
• The framework assesses seven domains: opinion scope/qualification fit, source/documentation support, methodology/reproducibility, benchmark literacy/fitness-for-purpose, case-specific linkage, transparency/auditability, and bias/independence disclosure.
• It is intended as a structured review aid, not a validated psychometric instrument, legal admissibility test, or substitute for adjudicator judgment.

Main Results:

• BORS100 provides a domain-level reliability profile with narrative explanation, scoring from 0-100.
• Proposed interpretation bands range from highly structured (85-100) to severely limited (below 40) profiles, requiring empirical calibration.
• The framework enhances the visibility of reviewed records, methods, benchmark analysis, case linkage, audit trails, and disclosure practices.

Conclusions:

• BORS100 offers a structured vocabulary for evaluating the completeness and quality of expert opinions in medical billing and reimbursement.
• Its current value lies in organizing and making visible the components supporting an expert opinion, facilitating independent review.
• BORS100 serves as a pilot framework for structured review, pending empirical validation and calibration.