Medical Unit's New Interpretation of ML-104 (California) (Ca

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Re: Medical Unit's New Interpretation of ML-104 (California) (Ca

Postby psych74 on Fri Nov 17, 2017 12:34 pm

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. :roll:
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Re: Medical Unit's New Interpretation of ML-104 (California) (Ca

Postby mytwocents on Sat Nov 18, 2017 3:07 pm

A declaration of Suzanne Honor-Vangerov, the former long-time manager of the DWC Medical Unit, has been filed in the Howard case, on behalf of the plaintiff QMEs. She claims that the language in the ML fee schedule that appears to require the agreement of the parties before a doctor can be paid for report preparation, is the result of a drafting error. The way she explains it makes sense. I have a PDF copy of the declaration but I don't know how to attach a document in a post. If someone can explain to me how to do this, I'll be happy to provide it.
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Re: Medical Unit's New Interpretation of ML-104 (California) (Ca

Postby appliedpsych on Sun Nov 19, 2017 7:36 pm

My Two... hit Post a Reply, go down to bottom of that page, and on the left side you should see two tabs, one of which says UPLOAD ATTACHMENT. Select the UPLOAD tab.

Then select CHOOSE FILE, and navigate to where you have the file on your computer. When you find the file you want to upload, hit ADD THE FILE.

I think that should do it.
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Re: Medical Unit's New Interpretation of ML-104 (California) (Ca

Postby psych74 on Mon Nov 20, 2017 9:09 am

To mytwocents et al: I realize that I never clarified that I totally disagree with the "Underground Regulations"/new interpretation of ML-104 and believe it will
result in more QMEs quitting and fewer doctors willing to become QMEs. I totally support CSIMS' interpretation of the ML-104 billing regulations and am glad to
learn that Suzanne Honor-Vangerov has made a declaration that is reasonable. Attorney Julius Young has an excellent blog on the issue: http://www.workerscompzone.com/2017/11/ ... -training/
My previous comment was simply a summary of the what I felt was the worst portion of the "Education Module" and NOT an endorsement of same. I sent along my negative comments to the DMC after completing the "training."
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Re: Medical Unit's New Interpretation of ML-104 (California) (Ca

Postby spreare on Mon Nov 20, 2017 12:12 pm

This is a letter I am writing the DWC principals. I will further edit on grammar etc. Any thoughts?

Dear DWC Agency Directors and Principals,

I have written the following letter as part of a comprehensive yet brief analyses of regarding my viewing of the uploaded video tutotial. I apologize in advance in that I have not received permission to e-mail the principals on this topic, yet my QME certificate does fall under the regulatory jurisdiction of your agency and so therefore I think it appropriate for me to send this e-mail. Nevertheless I do not expect a response from any departmental employee
Thank you for uploading the new training module on QME report writing and billing. I have to say that the video tutorial is completely different than how our initial course work and cont ed courses have trained us -- and these courses are credentialed by the DWC. To state that ML-104 requires pre-authorization, or, rather, written agreement, well this is not how it has been practiced, ever, that I am aware of; and it is not how it has been taught in any circumstance that I am aware of since 2003 when I was credentialed for the first time. Implying that written agreement is required destroys the intent of what a PQME needs to accomplish for the system at large: he/she is to act as a neutral evaluater. But giving a carrier the power to decide whether an extraordinary level exam can be done provides that one side unilateral veto power on how a report will be conducted. That means a very complex case with huge amounts of medical records, and or other complexities necessitating the ML-104, can be withheld by carriers for ulterior motives. I can tell you from first hand experience, the highest quality PQME's are the ones that have or have had, active practices. We are a busy lot. If we are given a very complex case and withheld the ability to spend an appropriate amount of time on it; and or required to bill at a much reduced rate within the context of a busy practice, someone will end up coming up short since the PQME provider will not invest the appropriate time levels.

Regarding causation only being addressed with denied cases:This statement implies a failed understanding of the system.Often times the parties may need a genuine expert witness (QME) opinion on the issue and so they ask in writing for the PQME to fully discuss causation regardless of the standing claim status. For example, the carrier may have given the IW the benefit of the doubt on the claim pending a PQME. Then what happens is the carrier or carrier attorney will send the PQME a cover letter explicitly requesting that PQME address causation as they are relying on the "full low-down." There was a non-represented case that I did a PQME within recent times that the claims examiner candidly told me that she was accepting the claim for now, but that she had some doubts on the causation issue and she needed it addressed and analyzed to settle the doubts one way or the other. Causation in this instance needed to be thoroughly analyzed in the light of many complex surroundings circumstances. The claims examiner, was a really great claims examiner, she had accepted the claim in good faith. This is a real-life scenario that happens on a not infrequent basis. There could be several scenarios that would alter the claim status based on the findings PQME re causation. It turned out, after thoroughly analyzing the issue of causation, the claimant's low back syndrome had nothing to do with the job. The claimant nor the claims examiner could have known, since neither were medical experts. So you see, just as a denied claim might become accepted, an accepted claim may become denied following a PQME. In addition, there can be accepted claims that still do not accept all the claimed body parts. So, you have an accepted claim, but denied body parts. Those denied body parts need to be addressed in causation even the underlying claim is accepted, and the IW is receiving benefits.

With respect to apportionment: perhaps the DWC is on more solid ground in requiring that it only be addressed when an applicant is permanent and stationary. But I still disagree for some very important reasons. Even before a case is P&S the parties often would like a strong apportionment rationale from the PQME because 50/100 times cases settle by C&R before the IW is P&S and the apportionment figures allow the parties to resolve the case in chief with a strong understanding of the apportionment values. So actually apportionment is really helpful to have prior to P&S and this is why it is so often specifically requested in the carrier's cover letter. Most carrier cover letters do not state "only address apportionment if IW is P&S." The carriers and AA often need to know where the IW stands relative to apportionment so the parties can effect a C&R. If you research settled claims you will find this high percentage of cases that settle prior to P&S by way of C&R and apportionment would often play that vital role to calculating the percentage of PD the settlement should benefit out at.
Let's get to the real problem facing this part of the industry: concentration of billing and report production procedures in the hands of a few management groups who charge percentages for their "management services." These practices strike me as Capping. Although I am not an attorney and presumably these groups have legally vetted their services, they are charging percentages on physician services and they [the management groups] are not actually physicians that are engaged in the process. They have incentives to gouge carriers to make up for the physician fees they are receiving percentages on. Think about it: as I understand they are receiving 50% of the physician fees, and marking or packaging their fees under other auspices; but we all know it is a form of capping. To correct this problem, I believe regulations should be introduced that do not allow non-physician participants to receive physician fees for QME reports. They should charge set amounts for transcriptions, or individual services that have no direct relation to the dollar amount of the final invoice. Of course then they might go away. In any case, perhaps creating regulations to dissuade third-party organizations from being indemnified of physician fee reimbursement percentages would go a long way in protecting the larger system.
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Re: Medical Unit's New Interpretation of ML-104 (California) (Ca

Postby mytwocents on Tue Nov 28, 2017 7:47 pm

Spreare, I followed your instructions on uploading a document but when I tried to upload the declaration, a message came up saying it was too big. I would think that CSIMS would have a copy and maybe they'd send it to you if you asked.
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Re: Medical Unit's New Interpretation of ML-104 (California) (Ca

Postby psych74 on Wed Nov 29, 2017 2:29 pm

I expected her Declaration to be excellent; but, it exceeded my expectations. ;)
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