Authors
Andrew M Klapper, Anthony N Dardano, Michael S Risin, Karla Maita, Monali Mahedia
Published in
Cureus. Volume 18. Issue 7. Pages e112462. Epub Jul 11, 2026.
Abstract
Medical billing, coding, reimbursement, No Surprises Act Independent Dispute Resolution (NSA/IDR), and medicolegal disputes frequently depend on expert opinions that vary substantially in transparency, evidentiary support, methodological discipline, and case-specific reasoning. Existing legal and administrative processes may assess expert reliability, but they do not provide a uniform rubric for evaluating the internal methodological quality of billing and reimbursement expert opinions across dispute settings. Billing Opinion Reliability Score 100 (BORS100) was developed as a proposed conceptual structured reliability assessment framework for expert opinions involving medical billing, coding, reimbursement, NSA/IDR, and related medicolegal questions. Domains were identified through a three-step process: structured review of published expert testimony standards, structured professional judgment literature, and psychometric instrument development principles; extraction of recurring reliability limitation categories; and iterative consolidation into seven scoring domains. The framework is intended to generate a domain-level reliability profile supported by a narrative explanation. It is not a validated psychometric instrument, a legal admissibility test, or a substitute for adjudicator judgment. BORS100 contains seven scoring domains: opinion scope and qualification fit (15 points); source and documentation support (15 points); methodology and reproducibility (20 points); benchmark literacy and fitness-for-purpose (15 points); case-specific clinical or procedural linkage (15 points); transparency and auditability (10 points); and bias and independence disclosure (10 points). Proposed interpretation bands range from highly structured and well-documented opinion profiles (85-100) to profiles with severe evaluability limitations (below 40). These bands are proposed as descriptive categories for pilot use and require empirical calibration before adoption as institutional thresholds, comparative rankings, or decision rules. BORS100 offers a structured vocabulary for assessing whether a billing or reimbursement expert opinion discloses the scope, data, method, benchmark logic, case-specific linkage, calculations, and conflicts necessary for independent review. Its current value is organizational rather than determinative: it makes visible the records reviewed, methods used, benchmark fitness analysis, case-specific linkage, audit trail, and disclosure practices supporting the opinion. Until empirical validation is completed, BORS100 should be used as a structured review aid and pilot framework, not as a binding standard, objective measurement instrument, legal admissibility test, or payment determination formula.
PMID:
42436700
Bibliographic data and abstract were imported from PubMed on 12 Jul 2026.
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