Which Medical Bill Number Counts in a Massachusetts Claim?

Here is the situation this article is about, in the shape it usually arrives. The hospital billed forty thousand dollars, the health insurer paid nine, the difference was written off, the patient never owed a cent of it, and an adjuster is now calling the medical damages nine thousand dollars. In Massachusetts that is not the law, and the opposite is not the law either. Under M.G.L. c. 233, sec. 79G itemized medical bills are admissible in evidence, and in Law v. Griffith, 457 Mass. 349 (2010) the Supreme Judicial Court held that a judge may not keep them out just because a third party paid less. The same decision held that the defense may not tell the jury what a particular insurer actually paid, but may call a representative of the provider to testify to the range of payments that provider accepts for those services. So the jury hears the full bill, never hears the payer, and finds fair and reasonable value somewhere in the room between the two figures. To talk through a specific claim, call Jim Glaser Law at (617) JIM-WINS. The line is answered 24 hours a day, and the first telephone consultation is offered without charge.

Two Numbers, and a State That Refuses to Pick One

Every injury claim with health coverage behind it produces two numbers for the same treatment. There is the charge the provider posted, and there is the smaller amount the provider agreed in advance to accept from that particular payer. The gap has a name in the case law. The Supreme Judicial Court defined it as “the difference between the original amount billed by a medical provider and the amount the provider agrees to accept as payment in full for the services provided”.

States split hard on which number a jury may hear. Some admit only the billed amount and treat the discount as none of the wrongdoer’s business. Some cap medical damages at what was actually paid. Massachusetts took neither road, and anyone reasoning from an out-of-state article about write-offs will get this wrong in a way that costs money.

What Massachusetts did instead was let both kinds of evidence in while keeping one specific fact out, which is the identity of the payer and the amount it paid on this plaintiff’s behalf. That is a narrow line, and its consequences run through settlement negotiation long before any case reaches a courtroom.

What the Statute Says

M.G.L. c. 233, sec. 79G is an evidence statute, and it is short about the thing that matters. Itemized bills and reports relating to medical, dental and hospital services “shall be admissible as evidence of the fair and reasonable charge for such services or the necessity of such services or treatments”.

Two features of that sentence get overlooked.

The first is that admissible is not the same as conclusive. The statute makes the bill evidence of a fair and reasonable charge. It does not make the bill the measure of damages, and it does not stop anyone from arguing that the fair and reasonable charge is a smaller number. Plenty of adjuster correspondence treats the bill as an asking price and the paid amount as the real value. Plenty of claimant correspondence treats the bill as a fixed entitlement. Both are reading something into sec. 79G that is not there.

The second is that sec. 79G comes with a procedural price. The bills are admissible only where “written notice of the intention to offer such bill or report as such evidence” has been given to the opposing party, together with a copy, by certified mail with return receipt requested, and “not less than ten days before the introduction of same into evidence”, with an affidavit of the notice and the return receipt filed with the clerk. Miss that and the statutory shortcut is gone, and the bills have to come in the long way, through a witness.

The same section then preserves the other side’s ability to fight. Nothing in it limits the right of any party to summon the provider “for the purpose of cross examination with respect to such bill, record and report or to rebut the contents thereof”. That sentence does more work in Massachusetts than most readers realize, and the next section is why.

Answer Capsule

In Massachusetts the jury sees the full amount the medical providers billed, not the discounted amount a health insurer paid. M.G.L. c. 233, sec. 79G makes itemized medical bills “admissible as evidence of the fair and reasonable charge for such services”, and in Law v. Griffith, 457 Mass. 349 (2010) the Supreme Judicial Court held that a trial judge may not exclude those bills merely because a third party paid a smaller negotiated amount. The same decision held that “evidence of amounts actually paid to the plaintiff’s medical providers is not admissible, but evidence may be introduced concerning the range of payments that the providers accept for the types of medical services that the plaintiff received”, and that the witness giving that testimony may not identify the plaintiff’s insurer or state what was paid on the plaintiff’s behalf. Neither the billed figure nor the paid figure controls; the jury finds fair and reasonable value. Massachusetts has one statutory exception, M.G.L. c. 231, sec. 60G, and it reaches only actions “against a provider of health care”, which means medical malpractice. This is general information about Massachusetts law and not legal advice.

Law v. Griffith, and the Facts Behind the Rule

The case that settled this in Massachusetts came out of an ordinary vehicle collision, and the numbers in it are worth stating because they show how much turns on the question.

The plaintiff was injured when the defendant’s vehicle struck hers. She needed surgery and physical therapy. Her medical bills totaled $112,269.94. She was a MassHealth participant, so her providers had agreed in advance to accept the Medicaid rate and could not bill her for the rest. The parties stipulated that $16,387.14 had actually been paid for those services.

The trial judge kept the bills out. His reasoning was that amounts nobody paid or expected to pay could not be relevant to the value of the services. The jury heard the stipulated $16,387.14 figure and nothing else, found the defendant seventy-five per cent liable, and returned a general verdict of $48,500. That was reduced by $12,125 for the plaintiff’s own twenty-five per cent share under M.G.L. c. 231, sec. 85, which provides that “any damages allowed shall be diminished in proportion to the amount of negligence attributable to the person for whose injury, damage or death recovery is made”. It was reduced again by $7,818.50 in personal injury protection benefits already received. Judgment entered for $28,556.50.

The Supreme Judicial Court reversed. On the first question it was blunt: “The judge’s ruling that the plaintiff’s medical bills were inadmissible was error.” The Legislature had declared bills admissible on the question of reasonable value, and a judge is not free to override that.

On the second question the Court did something more interesting than either side had asked for. It held that “evidence of amounts actually paid to the plaintiff’s medical providers is not admissible, but evidence may be introduced concerning the range of payments that the providers accept for the types of medical services that the plaintiff received”. It then reversed the judgment and remanded “for a new trial on the issue of damages”.

What the Defense Is Allowed to Do

This is the part left out of most versions of this topic in circulation, and it is the part that most affects what a Massachusetts claim is worth.

Law v. Griffith gave the defense a specific, court-designed route to a lower medical damages number. Reading the second sentence of sec. 79G, the Court concluded that a reasonable way to implement it is “to permit the defendant to call a representative of the particular medical provider whose bill the defendant wishes to challenge, and to elicit evidence concerning the provider’s stated charges and the range of payments that that provider accepts for the particular type or types of services the plaintiff received”.

The Court added that a defendant may also call an expert to testify generally about hospital billing practices and the system of discounting charges, and about the relationship between charges and reasonable value.

It went further in describing the problem it was solving. The Court observed that “doctors, hospitals, and other medical care providers have developed charge structures that may have little or no relationship to the reasonable value of the medical services at issue”. It added, in the same passage: “The only patients actually paying the stated charges are the uninsured, a small fraction of medical bill payors.”

That is a Massachusetts appellate court, in the very decision guaranteeing that the bills come into evidence, saying in the same breath that the posted charge may mean very little. Anyone reading Law v. Griffith as a promise of the billed amount has read half of it.

What the Defense Is Not Allowed to Do

The line the Court drew is precise, and it is where the collateral source rule survives.

The witness giving range-of-payments testimony may acknowledge that the range reflects amounts paid by both self-paying patients and third-party payors. But, the Court held, “the witness would not be permitted to identify the plaintiff’s insurer or third-party payor, or to testify to the amount actually paid on the plaintiff’s behalf”. Written evidence of the amounts paid on the plaintiff’s behalf is excluded on the same footing.

So the defense may say what that hospital generally accepts for that operation. It may not say what this claimant’s carrier paid for this operation, and it may not name the carrier. The abstraction is the whole protection.

The Court also described the jury instruction, and its shape tells you what the rule is for. It said it would be appropriate to instruct a jury in a way that acknowledges the widespread use of medical insurance, while explaining that “whether the plaintiff’s medical expenses were paid by her, covered by insurance, or otherwise paid on her behalf, is not relevant to the jury’s task”, which is to find the fair and reasonable value of the necessary medical services.

One question the Court expressly left open is the one an uninsured reader will care about most: “We do not reach the question whether an uninsured, self-paying patient would be permitted to introduce evidence of his or her full payment of the provider’s stated charges.” A full-text search of Supreme Judicial Court and Appeals Court decisions run for this article found that phrase in Law v. Griffith and nowhere else, which suggests the reserved question has not been taken up since 2010. That is a database search rather than a citator report, so treat it as a strong indication rather than a settled fact.

The Older Rule, and Why It Cuts Both Ways

The collateral source rule is not a claimant’s rule. It is a rule about what juries are not allowed to know, and Massachusetts has enforced it against both sides for a very long time.

Goldstein v. Gontarz, 364 Mass. 800 (1974) laid out the symmetry in four parts. A plaintiff “ordinarily may not show that the defendant is insured against liability”. A defendant “may not show that the plaintiff has received other compensation for his injury”, whether from accident insurance, workers compensation, an employer, or another source. A defendant may not assert or imply that he has no insurance, which the Court treated as the equivalent of a plea of poverty. And, fourth, “a plaintiff is forbidden to show that he has no resort to insurance or workmen’s compensation to cover the loss he has suffered”.

That fourth branch surprises people. Someone who paid every bill out of pocket, who has no coverage at all, and who wants the jury to know it, is asking for something Massachusetts law does not allow.

The reason given in Goldstein is about jury behavior rather than fairness in the abstract. Where outside payments do not reduce the defendant’s liability, evidence of them is irrelevant, and “jurors might be led by the irrelevancy to consider plaintiffs’ claims unimportant or trivial or to refuse plaintiffs’ verdicts or reduce them, believing that otherwise there would be unjust double recovery”.

Scott v. Garfield, 454 Mass. 790 (2009), decided the year before Law v. Griffith, shows how this plays out in a trial record. The defendants wanted the jury to hear what the providers actually accepted. The judge refused, and the Supreme Judicial Court found no abuse of discretion, noting that “the defendants made no evidentiary proffer, i.e., a showing that the health care providers had agreed to accept as full payment some amount less than the amount billed”. A year later Law v. Griffith described that exclusion as dictum and built the range-of-payments route in its place. The evidentiary proffer the Scott defendants never made is now the thing a Massachusetts defendant is expected to make.

Scott v. Garfield also approved a jury instruction that runs squarely against the injured person’s interest. The trial judge told the jury that “if the medical, hospital, rehabilitation, or physical therapy expenses were paid by a third party such as a medical insurance company or a health maintenance organization, that party can seek reimbursement from any amount paid from any judgment you may award”. The Supreme Judicial Court held that the instruction correctly stated the law under the medical lien statute. A Massachusetts jury can be told, in general terms, that somebody may have to be repaid out of what it awards.

Medical Malpractice Is the Exception the Legislature Wrote

Massachusetts does have a statutory collateral source offset, and it is a real one. It simply does not apply to most injury cases.

M.G.L. c. 231, sec. 60G applies to actions for malpractice, negligence, error, omission, mistake or the unauthorized rendering of professional services “against a provider of health care”. In such a case, on the defendant’s motion or the court’s own motion, the court “shall hear evidence of any amount of such damages incurred prior to the judgment which the defendant or defendants claim was replaced, compensated or indemnified” by Social Security, disability programs, health or accident insurance, wage continuation agreements, or “any other collateral source of benefits whatsoever”. Gratuitous payments and gifts are excluded, and so are workers compensation benefits under c. 152.

Where the court finds such replacement, subsection (b) provides that “it shall reduce the amount of the award by such finding, minus an amount equal to the premiums or other amounts paid by the plaintiff for such benefits for the one-year period immediately preceding the accrual of such action”.

Two things about sec. 60G surprise people, and they run in opposite directions.

The first favors the injured person. Where an award is reduced under this section, the payer that caused the reduction loses everything on the other end. Subsection (c) bars any such entity from recovering any amount against the plaintiff, and adds that it may not be “subrogated to the rights of the plaintiff against the defendant” and may not have “a lien against the plaintiff’s judgment”. The reduction and the lien do not both happen.

The second cuts the other way, and it is a large carve-out. Where the collateral source has a subrogation right “based in any federal law”, the court “shall not reduce the award by the amounts received prior to judgment from such collateral source”, and those amounts may be recovered under the federal law instead. Medicare is the obvious example. Subsection (e) makes a parallel carve-out for public assistance benefits, preserving the Commonwealth’s subrogation and lien rights and directing that a court not reduce an award by them.

The Supreme Judicial Court read sec. 60G as the boundary of legislative intent. In Law v. Griffith it noted that “the Legislature has modified our collateral source rule, but only with respect to awards of medical damages in medical malpractice cases”, and treated that narrow modification as a reason to leave any further change to the Legislature. If you are reading about a Massachusetts collateral source offset and your case is a vehicle crash, a fall, or a dog bite, sec. 60G is not your statute. Whether a claim counts as a malpractice claim at all is a separate question with its own deadline rules, set out in the Massachusetts medical malpractice statute of limitations.

Where the Write-Off Actually Goes

There is a comfortable misreading of all this. The bill was forty thousand, the jury may hear forty thousand, the insurer only paid nine, so thirty-one thousand dollars of pure profit is sitting in the case. That is not how a real file closes.

The write-off is not automatically the claimant’s. What reaches a client depends on what the payer is entitled to take back, and in Massachusetts that is set by statute rather than by negotiation. A hospital lien under c. 111, sec. 70A behaves very differently from a MassHealth claim under c. 118E, sec. 22, and both behave differently from a workers compensation lien under c. 152, sec. 15. The full map of who is repaid out of a Massachusetts recovery, and in what order, is in who gets paid out of your Massachusetts injury settlement.

The number the jury finds is also not the number anyone keeps, for a second reason. Comparative fault reduces it, as it did in Law v. Griffith itself, and the mechanics of that reduction are set out in Massachusetts comparative negligence. Personal injury protection benefits already paid come off as well, which is what the $7,818.50 deduction in Law v. Griffith was.

The contingent fee comes out of the same recovery, and what that fee may be and how it is calculated is set by rule rather than by custom, as set out in what Massachusetts personal injury lawyers charge.

Working in the other direction, M.G.L. c. 231, sec. 6B adds interest to a verdict for personal injuries “at the rate of twelve per cent per annum from the date of commencement of the action”. On a case that takes three years to reach trial that is a substantial number, and it is calculated on the damages the jury found rather than on what anybody paid.

The Bill Also Runs the Gate on Pain and Suffering

In a Massachusetts motor vehicle case the size of the medical bill does something else entirely, and this is where the billed-versus-paid argument stops being academic.

M.G.L. c. 231, sec. 6D bars recovery for pain and suffering in a motor vehicle tort case unless the reasonable and necessary expenses of treating the injury “are determined to be in excess of two thousand dollars”, with exceptions for death, loss of a body member, permanent and serious disfigurement, certain losses of sight or hearing, and any fracture.

Read that against the write-off problem. If the threshold were measured by what an insurer paid, a claim with four thousand dollars of charges and eleven hundred dollars of payments would have no pain and suffering claim at all. If it is measured by the reasonable and necessary expenses incurred, the same claim clears. The statutory language is expenses incurred in treating the injury, determined to be reasonable and necessary, and sec. 79G makes the bill admissible evidence of the reasonable charge. That is the argument, and on a modest case it is worth a great deal more than the difference in the medical damages number.

There is a genuine oddity in the statute books here that anyone reading the raw law should know about. The last paragraph of M.G.L. c. 90, sec. 34M still turns on whether expenses “exceed or do not exceed five hundred dollars”, a determination it says “may affect an injured’s person’s rights under section six D of chapter two hundred and thirty-one”. Section 6D itself now reads two thousand dollars. The cross-reference in sec. 34M was not updated when the threshold moved, and sec. 6D is the section that states the threshold. The threshold, how it is measured, and the injuries that bypass it are covered in the Massachusetts serious injury threshold.

The interaction with no-fault benefits matters too, because sec. 34M provides that personal injury protection benefits “are granted in lieu of damages otherwise recoverable by the injured person or persons in tort as a result of an accident occurring within this commonwealth”. How the first medical bills get paid, and what happens when that layer runs out, is set out in Massachusetts personal injury protection.

What a Careful File Looks Like

None of this is self-executing. A few things separate a claim where the argument is available from one where it is not.

Keep the itemized bills, not the explanation of benefits summaries. Section 79G attaches to an itemized bill subscribed and sworn to under the penalties of perjury by the provider, and a printout showing an allowed amount and a patient responsibility is a different document doing a different job. The bills are what the statute admits.

Watch the ten-day notice. The statutory route into evidence is conditioned on written notice by certified mail with the return receipt filed with the clerk. That small piece of housekeeping decides whether a stack of bills is admissible on paper or needs a live witness.

Expect the range-of-payments attack instead of being surprised by it. Since Law v. Griffith the defense has a named, court-approved way to put a lower number in front of a jury, and it does not require touching anyone’s insurance. Preparing for a provider representative to testify about what that provider generally accepts is part of valuing a case honestly.

Do not volunteer coverage, and do not volunteer the absence of it. Goldstein cuts in both directions, and telling an adjuster or a jury that you paid everything yourself is offering evidence Massachusetts does not permit.

Handle the reimbursement side in parallel rather than afterwards. The write-off is only yours to the extent nobody is entitled to claw it back, and some Massachusetts reimbursement rights carry notice duties that run on their own clocks. What the insurer’s own doctor is entitled to examine along the way is covered in the insurer medical exam, and how adjusters build a reduction argument out of the treatment record is covered in mitigating damages.

Keep the filing deadline in view while the bills are still accumulating. For an ordinary Massachusetts negligence claim the limit is generally three years, and the full set of deadlines by claim type is in the Massachusetts statute of limitations for every claim. Medical damages are one component of a larger figure, and the rest of that figure is in Massachusetts car accident case value. What happens to the recovery afterward, at tax time, is in whether a Massachusetts injury settlement is taxable.

Frequently Asked Questions

Q: Does the jury in Massachusetts see my full medical bill or only what my insurance paid?

A: The full bill. M.G.L. c. 233, sec. 79G makes itemized medical bills “admissible as evidence of the fair and reasonable charge for such services”, and in Law v. Griffith, 457 Mass. 349 (2010) the Supreme Judicial Court held that a trial judge may not exclude them because a third party paid a smaller negotiated amount. In that case the bills totaled $112,269.94 while $16,387.14 had actually been paid, and the Court held that keeping the bills out was error. Admissible is not the same as conclusive, though. The bill is evidence of reasonable value rather than a fixed entitlement.

Q: What is a medical bill write-off?

A: The Supreme Judicial Court defined it as “the difference between the original amount billed by a medical provider and the amount the provider agrees to accept as payment in full for the services provided”. It arises because providers negotiate discounts with insurers and with government programs in advance, so the posted charge and the accepted payment end up as two different numbers for the same treatment.

Q: Can the insurance company tell the jury my health insurer paid a discounted amount?

A: No, and this is the sharpest line in Massachusetts law on the subject. Law v. Griffith held that “evidence of amounts actually paid to the plaintiff’s medical providers is not admissible”, and that a witness “would not be permitted to identify the plaintiff’s insurer or third-party payor, or to testify to the amount actually paid on the plaintiff’s behalf”. Written evidence of those amounts is excluded on the same basis.

Q: So what can the defense do about a bill it thinks is inflated?

A: It can attack the number in the abstract. The same decision permits a defendant “to call a representative of the particular medical provider whose bill the defendant wishes to challenge, and to elicit evidence concerning the provider’s stated charges and the range of payments that that provider accepts for the particular type or types of services the plaintiff received”. A defendant may also call an expert to testify generally about billing and discounting practices. What no witness may do is connect any of it to the plaintiff or the plaintiff’s payer.

Q: What is the collateral source rule in Massachusetts?

A: It is the common-law rule that compensation an injured person receives from a source other than the wrongdoer does not reduce the wrongdoer’s liability, and that juries are generally not told about it. Goldstein v. Gontarz, 364 Mass. 800 (1974) states the rationale: because outside payments do not reduce the defendant’s liability, evidence of them is irrelevant, and “jurors might be led by the irrelevancy to consider plaintiffs’ claims unimportant or trivial or to refuse plaintiffs’ verdicts or reduce them, believing that otherwise there would be unjust double recovery”.

Q: Does the collateral source rule ever work against an injured person?

A: Yes, in two ways people do not expect. Goldstein v. Gontarz holds that “a plaintiff is forbidden to show that he has no resort to insurance or workmen’s compensation to cover the loss he has suffered”, so someone uninsured who paid everything out of pocket cannot tell the jury so. And in Scott v. Garfield, 454 Mass. 790 (2009) the Supreme Judicial Court approved an instruction telling a jury that a third party such as a medical insurance company or a health maintenance organization “can seek reimbursement from any amount paid from any judgment you may award”.

Q: Is the rule different in a Massachusetts medical malpractice case?

A: Yes, and this is the one statutory exception. M.G.L. c. 231, sec. 60G applies to claims “against a provider of health care” and directs the court, after the verdict, to hear evidence of amounts that were “replaced, compensated or indemnified” by insurance and similar sources, then to reduce the award accordingly, less the premiums the plaintiff paid in the year before the claim accrued. It does not apply to vehicle crashes, falls, dog bites or any other ordinary negligence claim.

Q: If a malpractice award is reduced that way, does the health insurer still get repaid?

A: Generally not out of the plaintiff’s recovery. Subsection (c) of sec. 60G bars the collateral source whose payments caused the reduction from recovering any amount against the plaintiff, and provides that it may not be “subrogated to the rights of the plaintiff against the defendant” and may not have “a lien against the plaintiff’s judgment”. The important carve-out is for a collateral source whose subrogation right is “based in any federal law”, where the statute directs that the award not be reduced and the federal recovery proceeds instead. Subsection (e) preserves the Commonwealth’s public assistance rights in a parallel way.

Q: Do I get to keep the difference between the billed amount and the paid amount?

A: Not automatically, and often not at all. What a jury finds is fair and reasonable value, which can land well below the billed figure. What survives from there depends on comparative fault, on personal injury protection benefits already paid, and on who holds a statutory right to be repaid out of the recovery. Hospital liens, MassHealth and workers compensation each operate differently in Massachusetts.

Q: Does the billed amount count toward the $2,000 threshold for pain and suffering?

A: This is where the argument matters most on a modest claim. M.G.L. c. 231, sec. 6D allows pain and suffering damages in a motor vehicle case only where the reasonable and necessary expenses of treatment “are determined to be in excess of two thousand dollars”, unless the injury caused death, loss of a body member, permanent and serious disfigurement, certain losses of sight or hearing, or a fracture. The statute measures reasonable and necessary expenses incurred, and sec. 79G makes the itemized bill admissible evidence of the reasonable charge, so the billed figure is evidence going to the threshold and not merely to the size of an award.

Q: What do I have to do to get my medical bills into evidence?

A: Section 79G conditions admissibility on procedure. Written notice of the intention to offer the bill, with a copy, must go to the opposing party by certified mail with return receipt requested “not less than ten days before the introduction of same into evidence”, and an affidavit of that notice together with the return receipt must be filed with the clerk. The bill itself has to be subscribed and sworn to under the penalties of perjury by the provider. Without that the statutory shortcut is unavailable and the bills have to be proved through a witness.

Q: Is Jimmy Knows AI giving me legal advice?

A: No. This is general information about Massachusetts law, not legal advice, and reading it does not create an attorney-client relationship. Whether the billed amount, the accepted range, or a threshold argument matters in a particular claim depends on facts a general article cannot see. To discuss a specific situation, call Jim Glaser Law at (617) JIM-WINS. The line is answered 24 hours a day. The first telephone consultation is free.

Talking to a Lawyer

The expensive mistake here is settling a claim on the adjuster’s arithmetic. An adjuster who values medical damages at what the health insurer paid is applying a rule Massachusetts does not have, and Law v. Griffith says so in plain terms. How that conversation is usually structured, and what it is reasonable to say during it, is covered in dealing with the insurance adjuster after a Massachusetts crash. The mirror-image mistake is treating the posted charge as money already earned, when the same decision hands the defense a specific route to argue that the charge means very little. The real number lives between the two, and on a smaller case the threshold argument under M.G.L. c. 231, sec. 6D can be worth more than the medical damages themselves.

Jim Glaser Law takes calls about Massachusetts injury claims, including claims where an insurer has already valued the medical bills at the discounted amount it paid. The line at (617) JIM-WINS is answered 24 hours a day. The first telephone consultation is free.