If you don't want a five figure bill, don't send 5000 pages

[jobmdpsych]

So what happens on a case when a doctor admits in a depo that he didn't review the records personally and he instead sent them out a record review service?

[mytwocents]

vampire: I’m not sure I understand your comment. Are you saying that the paramount goal here is to minimize the time spent by the attorneys on both sides and keep the costs down for the insurance company? If so, it’s going to cost the insurance company more to pay the doctor to review a stack of clearly irrelevant records than to pay the defense attorney to vet them for relevance. By the same rationale one could argue that it’s more efficient for both parties to offer all of the products of discovery into evidence at a trial, relevant or not, and let the judge sort it out. One problem with this for both judges and doctors is that then they have to waste their time trying to figure out why the parties think the documents are relevant. Of course, there are QMEs who would be delighted to get 5000 pieces of paper, turn them over to their record reviewer, produce a 150 page report, and enjoy a billing bonanza. So it may be false economy when it comes to cost containment.

jobmdpsych: There's nothing wrong with having someone other than the doctor summarize the records as long as, per Labor Code section 4628, the doctor reviews "the excerpts and the entire outline" and "makes additional inquiries and examinations as are necessary and appropriate to identify and determine the relevant medical issues." What's not okay is for the doctor to rely exclusively on the summary and claim to have personally spent the time that the record reviewer spent. I have my doubts that any doctor would admit to that in a deposition after swearing to something different in the report.

[jobmdpsych]

Therein lies the central fallacy. If the whole purpose of excess records is completeness, yet it is so cumbersome that the doctor has to farm it out and isn't looking at the source documents, what's the point?

[appliedpsych]

I had a case a few years ago where a pro per applicant was battling with an attorney for a self-insured employer. The case had already been going on for a while, and the applicant had either fired or had several attorneys back out of her case and was now pro per. She made some pretty wild accusations about past attorneys, which I won't go into, but apparently the WCAB Judge felt that the records of the case, over 14,000 pages, were so important to the case that he ordered QME's by psychologist (me), orthopedic surgeon, internal medicine, dentist and another I cannot recall.

The point is that the Trier of Fact felt that the only way for the applicant to get a fair shake in this complicated case was to send ALL records to ALL QME's. The Trier of Fact made no effort to have his staff or anyone else parse out different records for different QME's. In fact the order was specific that each QME get a digital set of all the records, and that each QME was to closely review all records, and determine how they folded into the issues of the case in each QME specialty.

So, if a WCAB judge, the major authority for the proper settlement of industrial injury claims, takes such an approach, what does this say about the importance of records, whether they are voluminous or not?

[mytwocents]

Based on my experience with pro pers, they tend to be suspicious and don’t trust anyone. If anything is left out and they don’t get what they want, they may believe that 1) the omission was purposeful, and 2) they would have gotten what they wanted if the doctor had seen the missing documents. So the judge was probably smart to send everything to the doctors under those circumstances.

Otherwise, I think it depends on the case and the records in question. I don’t think jobmdpsych is a anomaly. I have heard many doctors complain about irrelevant records. If you look at the commentary on the DWC’s website in response to the proposed amendments to the Medical-Legal Fee Schedule last Spring, you will see lots of doctors complaining about this. It can particularly be a problem when the evaluation is legitimately only an ML 102 and the doctor is forced to spend hours reviewing irrelevant records so that he ends up making $50 an hour.

[jobmdpsych]

Demanding every specialist read 14000 pages for the sake of completeness reveals a fundamental psychological misunderstanding on how to obtain the best work product from real people. That could be a 100K decision by the judge with that many specialists.

Simply put, there is a level of detail and volume of work that detracts from the excellence of the report. It is not humanly possible to read and comprehend that volume unless one shuts down a practice for a month and goes into hibernation.

Beyond a certain volume, the reader is skimming, not reading. Or not reading at all, in the case of 2700 page bills like the ACA which was passed without Congress reading it.

This is a societal problem that is worsening. People are confusing depth of understanding and clarity of understanding, and the default position is to always dig in deeper even though it's not germane to the question at hand.

The entire US Constitution is 20 pages. The blueprint for a Republic.

A couple of ML102s combined with a document dump is enough to get a QME to just quit and I know a few that have.

Anyway, it's good to see some acknowledgement of a serious problem after the initial denials and dismissiveness. The decline in the QME numbers says it all.

[appliedpsych]

I think that the decline in QME numbers has very little to do with the volume of documents received.

It is due to the sudden outrageous change in rules that had been in place for years by a DWC attorney who decided to re-interpret the med-legal billing rules in his own image... and threaten QME's with referral to their ethics boards for following long-standing procedures.

[jobmdpsych]

No doubt that was a big factor though it was tied into this issue because big bills were a flag. Anecdotally, I see a lot of burnout on the issue of records. We'll see what happens to the numbers in the next few years but I know plenty of people who dropped out unrelated to the QME purge.

[appliedpsych]

PLUS the new regs are hoping to limit report writing time to 3 hours - quite ridiculous on a QME dealing with psychological and/or neuropsychological issues, even on a case with only 500 pages of records.

The DWC should add at the end of their new regs, if approved, "sorry folks, we and the insurance companies just decided to make it clear that the final cost of a QME evaluation is way more important than a clear and well done evaluation of an injured worker".

[mytwocents]

You both make very good points. There are abusers and victims on all sides in this affair. What is needed is an updated fee schedule that takes into consideration the needs of the parties, the rights of the doctors to adequate compensation, and the limitations of the DWC Medical Unit that is charged with the task of overseeing the process. At the same time, there is something to be said about the economics of the case. Whether he/she has earned it or not, it doesn’t make sense to pay a QME $20K to write a report that resolves a dispute over $10K. In that case, the insurance company might as well give the $10K to the injured worker and keep the rest.