4060 (California)

[courtmechanic]

Hello i am new to the forum but i have a question, section 4060 which includes 4061 and 4062 states that this section does not apply where there is a body part accepted is this the correct interpretation? the scenario is ortho injury is accepted and treating doctor requests a psych evaluation can the psych eval be self procured or do we still follow 4061 or 4062.

any thoughts on this will be greatly appreciated.

[gaiassoul1@yahoo.com]

Labor Code section 4060 examinations are specifically for a denied claim where NO body parts are accepted.

If you have a claim with disputed body parts that becomes a nature and extent dispute which for all injuries after 1/1/05 must be addressed via the Labor Code Section 4061 an 4062 medical-legal discovery guidelines.

In your scenario if the pruimary treating physician requested authorization for a psychiatric evaluation and this was then properly submitted for utilization referral, after expiration of the UR times lines (main reason all requests for treatment should be mailed by certified mail with return receipt --- so you know the day the ins. co or TPA received it) Applicant is then free to self-procur TREATMENT. Any medical care at the referral of the primary treating physician is TREATMENT, not medical-legal.

IF defense disputes the psyche reporting and "body part" they have a duty to object, suggest at least one AME and then either go the AME or state -panel QME reporting. The only way medical-legal charges apply for injury after 1/1/05 -- is if the physician is desingated as an AME, or their name is left after the strike process on the state QME panel.

[courtmechanic]

thank you so much for this info....new question is diagnostic testing medical legal

[courtmechanic]

also while i have your attention, i have an accepted injury where i contact the adjuster and she forwarded me to the bill review company who did the and recommended payment, the adjuster put no pay and sent the file to HCRG and now they are trying to negotiate, the review came back at $5100.00 and they offered $1500.00 do you think a motion for cost and sanctions for frivilous delay is appropriate?

[steve appell]

Hello Mechanic:
Diagnostic testing can be m/l or treatment depending on how it is used and by who. For example, an MRI would be M/l if requested by an AME. However, it would generally be considered treatment if requested by a PTP.

Regarding your accepted injury and bill review totaling $5100 with a $1500 offer, does the defense have medical evidence the services are not reasonable or necessary? Is the applicant's case in chief resolved? Your motion for cost and sanctions may be premature.

[courtmechanic]

Hey Steve,

the point of the motion is to try to get the carrier to make the payment now or if i have to go to trial for any reason (carrier has not served any evidence refute reasonableness or necessity) the motion will be filed. its more for leaverage. what do you think

[steve appell]

Mechanic:
I would make a demand for the complete medical file, and I would not file a motion for costs & sanctions until you are certain that non payment is frivilous.

[gaiassoul1@yahoo.com]

also while i have your attention, i have an accepted injury where i contact the adjuster and she forwarded me to the bill review company who did the and recommended payment, the adjuster put no pay and sent the file to HCRG and now they are trying to negotiate, the review came back at $5100.00 and they offered $1500.00 do you think a motion for cost and sanctions for frivilous delay is appropriate?

Why did she stamp bill no-pay, disputed or denied body parts? Alleging an MPN? need more info... to determine, can't really file for cost and sanctions unless the case-in-chief is resolved for treatment bills.

Steve covered Med-legal diagnostics, depends on who orders it and their role is determined as discussed above.

[courtmechanic]

she really didnt stamp the billing no pay, she just did not authorize payment .

[courtmechanic]

what if the parties go to an AME regarding causation and the AME finds injury and in his reports states that treatment rendered was reasonable and necessary ? isnt the carrier supposed to start paying once the issue of causation is resolved?