Insight Reconsidering Medical Liens: Insurance Billing Requirements and Statutory Constraints After DeKlotz

This article was originally published in the May 2026 Edition of The Advocate – the official publication of the Idaho State Bar. Online access to the original version of this article can be found here.

In the administration of healthcare services, the relationship between providers, insurers, and patients is governed not only by contract, but also by a complex statutory framework regulating billing and collection practices. Disputes may arise when providers pursue payment through mechanisms that circumvent traditional insurance billing, raising questions about the permissible scope of those practices under applicable law. One such mechanism – the medical lien – allows providers to assert an interest in a patient’s potential recovery from a third-party tortfeasor, thereby introducing legal and financial considerations into the post-treatment landscape.

The Idaho Supreme Court’s decision in DeKlotz v. NS Support, LLC addresses the extent to which such collection practices are constrained by the Idaho Patient Act. Specifically, the case examines whether the filing of a medical lien prior to billing a patient’s insurance constitutes an “extraordinary collection action” prohibited by statute. Although framed as a matter of statutory interpretation, the Court’s analysis carries broader implications for the regulation of medical debt collection and the procedural obligations imposed on healthcare providers.

This article examines the Court’s interpretation of the Idaho Patient Act (IPA), its articulation of the criteria governing extraordinary collection actions, whether a medical provider may sidestep a patient’s insurance, and the resulting impact on the use and enforceability of medical liens in Idaho.

The DeKlotz Decision

On July 2, 2021, Guy DeKlotz was struck by a negligent driver and was rushed to St. Alphonsus Regional Medical Center where he was treated by the on-call physician whom he did not choose, negotiate with, or even meet until after surgery.¹ DeKlotz suffered a spinal fracture as a result of his injuries and required surgery and extensive post-operative care.² DeKlotz had medical insurance through SelectHealth, and naturally assumed (as anyone would) that his surgeon would submit his invoices and bills to insurance.³

Unfortunately for DeKlotz, Paul Montalbano, his on-call and treating physician, did not. Instead, Dr. Montalbano sent DeKlotz separate invoices and then recorded a medical lien for $183,829.⁴ The lien didn’t attach to DeKlotz’s home or bank account, but something equally as valuable: his personal injury claims against the negligent driver who caused his injuries.

Dr. Montalbano was able to do this under Idaho Code § 45-704B, which states that medical provider or association licensed in the state of Idaho “shall be entitled to a lien for the reasonable charges for medical care and treatment rendered an injured person upon any and all causes of action, suits, claims, counterclaims, or demands accruing to the person to whom such care and treatment was furnished . . . on account of injuries giving rise to such causes of action and that necessitate such medical care and treatment.”

Shortly after the lien was filed, DeKlotz retained legal counsel and fought to remove the lien. Specifically he sought a declaratory judgment that Dr. Montalbano violated the Idaho Patient Act⁵ by failing to bill his insurance prior to filing the medical lien.⁶ The district court held that Dr. Montalbano’s lien did not violate the IPA because it was not subject to the IPA because the lien was not considered an “extraordinary collection action.”⁷ DeKlotz appealed, and the Idaho Supreme Court heard arguments in May 2025.

On August 19, 2025, the Court released its opinion and held that Dr. Montalbano’s medical lien fell within and violated the IPA because the lien was considered an extraordinary collection action.⁸ The IPA was enacted in part to “govern the fair collection of debts owed to healthcare providers,” but also to protect Idaho citizens from unfair billing practices where patients “find themselves in collection actions for debts they were unaware of, [and] from health care providers whom they don’t recognize.”⁹

The IPA does this by, among other things, prohibiting medical providers from engaging in “extraordinary collection actions” prior to submitting all medical expenses to the patient’s insurance within forty-five days from the date they received medical treatment.¹⁰ The court held that there are two criteria that must be met for an action to be considered an extraordinary collection action under the I.C. § 48-304:

1. the physician must take one of the actions defined under I.C. § 48-303(3)(a); and
2. the action must have been done “in connection with a patient’s debt.”¹¹

The Court explained that under the IPA an “extraordinary collection action” is defined in part as “[c]ommencing any judicial or legal action or filing or recording any document in relation thereto, including but not limited to placing a lien on a person’s property or assets.”¹² The Court re-emphasized that one’s right to initiate legal action is considered personal property under Idaho law.¹³ The Court held that because Dr. Montalbano placed a lien on DeKlotz’s personal injury claim, he met the first criteria.

The Court then turned to the question of if Dr. Montalbano’s lien was done in connection with DeKlotz’s debt. The Court found that it was because the language of a contract signed by DeKlotz in essence stated that Dr. Montalbano could place a medical lien on DeKlotz’s claims against the negligent driver for the payment of his services.¹⁴

Beyond resolving a question of statutory interpretation by defining extraordinary collection actions, the Court’s ruling impacts the litigation of similar cases for both patients and doctors going forward.

Implications

For doctors, DeKlotz requires a physician to ensure that a patient’s insurance has been billed prior to filing any lien against the patient for services rendered. This requirement is significant because a failure to comply will likely result in dismissal of the physician’s lien. By following the procedural requirements of the IPA as outlined in DeKlotz, doctors protect themselves from having to defend against improper lien filings or a complete dismissal of their claim which could result in a delayed resolution of their claims and unnecessarily increase litigation expenses.

For patients, DeKlotz provides a clear procedural basis for seeking summary judgment to dispose of improper medical lien claims at an early stage of litigation. If a doctor fails to bill a patient’s insurance prior to filing a lien, that failure constitutes a noncompliance under the IPA and renders the lien invalid as a matter of law. In such circumstances, patients should promptly move for summary judgment under Idaho Rule of Civil Procedure 56, as no genuine issue of material fact exists regarding the doctor’s failure to satisfy a statutory condition precedent to lien enforcement. By clarifying that physicians must bill a patient’s insurance before pursuing lien-based collection, DeKlotz allows patients to efficiently terminate noncompliant claims without engaging in prolonged litigation.

While DeKlotz shapes litigation strategy for the parties, it also places trial courts in a critical gatekeeping role by supplying a clear framework for assessing the validity of medical liens under the IPA. DeKlotz empowers judges to evaluate the lien validity through a straightforward threshold inquiry: whether the physician billed the patient’s insurance prior to filing the lien and whether the lien was filed in connection with a patient’s debt for medical services rendered. When these statutory prerequisites are not satisfied, the lien constitutes an improper medical lien under the IPA and should be dismissed as a matter of law. This approach promotes judicial economy by allowing trial courts to resolve noncompliant lien claims at an early stage of litigation, thereby reducing unnecessary discovery and motion practice.

Conclusion

The Courts decision in DeKlotz re-enforces the Legislatures intent to protect its citizens from unfair medical collection practices by clarifying that the scope of extraordinary collection actions means the filing of a lien against a patient’s personal injury claim against a tortfeasor is considered personal property. It establishes a clear procedural framework for the parties and trial courts to follow in these types of cases.

For plaintiffs, it requires them to ensure that a patient’s insurance has been properly billed prior to filing a lien; this protects the plaintiff from having to defend against improper lien filings or a complete dismissal of their claim which could result in a delayed resolution of their claims and unnecessarily increase litigation expenses. For Defendants, it provides a straightforward basis for seeking a summary judgment under Idaho Rule of Civil Procedure 56 in the early stages of litigation. For judges, it outlines a clear threshold inquiry for these types of cases that promotes the judicial economy and ensures a consistent enforcement of the legislature’s intent.

Endnotes

1. DeKlotz v. NS Support, LLC, 574 P.3d 328, 330 (Idaho 2025).
2. Id.
3. Id.
4. Id.
5. I.C. § 48-300.
6. DeKlotz, 574 P.3d at 331.
7. Id. at 330.
8. See generally, DeKlotz, LLC, 574 P.3d at 328. See also Thomas J. Mortell and Jean E. Schroeder, Navigating the Idaho Patient Act and Medical Liens: Protecting Patients and Supporting Providers, The Advocate, Nov/Dec 2025 at 20.
9. I.C. § 48-302.
10. I.C. § 48-304(1)(a).
11. DeKlotz, 574 P.3d at 333.
12. I.C. § 48-303(3)(a) (emphasis added).
13. DeKlotz, 574 P.3d at 333.
14. Id.

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