NEW Rules for ML-104 billing (California) (California)

[psych74]

The new DWC "Educational Module" contains a section on "How to properly identify and apply the complexity factors in the medical-legal fee schedule." There are 3 ways for a QME report to qualify as an ML-104; but, ONLY ONE of these allows billing for Report Preparation (!) The free module is worth taking to know how to bill and you get an hour of CME/QME credit. My takeaway was getting an agreement IN WRITING, PRIOR to the evaluation, that the evaluation involves extraordinary circumstances.
psych74
 
Posts: 78
Joined: Sun Apr 17, 2011 9:55 am

[Manila]

The "new rules" are controversial and in many circles considered "underground" interpretations and contrary to the intended ways the "rules" are supposed to be used. CSIMS has posted information about this and evidently there is some litigation about the DWC denying QME re-applications because of the way doctors billed for med-legal reports based upon the usual way versus the so-called "new" and correct way promulgated as of late by certain people in the DWC. As far as getting the AA and the DA/IC to sign an agreement in advance of the med-legal appointment as a means of ensuring the doctor gets reimbursement for time writing the report, while the AA's are congenial the DA/IC, in my experience, rarely respond to requests to deem the evaluation "extraordinarily complex - which is needed from both parties for report writing time to be paid." I suspect this is yet another way for the IC's to reduce pay to doctors. If this continues I suspect there will be very few high caliber doctors willing to do AME/QME work if there is no pay for time needed to write a complicated and lenghty report. Dealing with the w/c system is already onerous and antagonistic toward doctors with all of the problems with UR/Bill Review, etc. This latest turn of events with the "new rules" for medical-legal makes it worse and is an added disincentive for doctors to do comp. related work.

[cmunday]

Manila et. al.

The great irony is that lousy reports from less sophisticated med-legal examiners often end up costing the IC more. Depositions, inability to resolve the case because clear answers to crucial issues have not been provided, bounce backs from the Trier of Fact, complete tossing of the report by Trier of Fact as "not substantial medical evidence". We have been fairly successful in getting pre-approval and while in actuality I don't know the motives of the parties my belief is that they are eager to get a decent report that enables them to resolve the case. I would add though that mostly I'm seeing very complex cases. Perhaps for "simpler" cases the above doesn't apply. I have gotten feedback from attorneys on both sides that they do not like these "new" rules and can't think of a single attorney outside of the administration who supported them.

[Manila]

"The great irony is that lousy reports from less sophisticated med-legal examiners often end up costing the IC more" may indeed be true but from my 30 years of experience in the comp system , comp insurers far too often do not do the smart thing and instead do the thing that in the moment appears to CA's as "cost effective", i.e., the thing that pays for the least expensive medical intervention or in this case least expensive med-legal report.