Page 1 of 2

PTP Med-Legal Initial Report and TF (California)

PostPosted: Fri Apr 03, 2009 11:44 am
I have a case that settled with a 5K Thomas Finding. The IW file a false claim after he was demoted. The PTP is psychologist and billed a ML-103 and some tests. The IC never sent a deniel for the billing. The IC offered 10%.

Should the IC at least pay for the ML-103? The psych is the PTP.


Re: PTP Med-Legal Initial Report and TF (California)

PostPosted: Fri Apr 03, 2009 12:57 pm
Yes all medical legal and required medical legal testing should be paid for...definitely.

Re: PTP Med-Legal Initial Report and TF (California)

PostPosted: Fri Apr 03, 2009 4:18 pm
by rider001
You can only be one thing a QME or a treator not both unless authorized to so. If the psych was a valid QME and the AME dance was preformed then you have a valid arguement for full payment of the QME and testing. Not sure where it is or if it still exists in labor code but 96100 pyscholgocial testing is only payable up to five hours.

Re: PTP Med-Legal Initial Report and TF (California)

PostPosted: Fri Apr 03, 2009 5:59 pm
sorry, I initially missed that the psych was a can't be a treater and bill med-legal...rider is 100% correct in his assessment.

Re: PTP Med-Legal Initial Report and TF (California)

PostPosted: Fri Apr 03, 2009 8:02 pm
by jonbrissman
Au contraire, mon freres -- a PTP may bill medical-legal in certain circumstances. Note the definitions in 8 CCR 9793(c)(2) and note 8 CCR 9795(d) [-92 modifier identifies a medical-legal report prepared by the PTP].

The report still must be requested by a party to prove or disprove a contested claim or a disputed medical fact, and the report must contain the substance listed in 8 CCR 10606 and the disclosures required by LC Sect. 4628 and 5703(a).

Psychological or psychiatric medical-legal reports are nearly always billed at ML104, because usually 4+ of the complexity factors listed in ML103 are present. If this PTP's medical-legal reporting was validly requested, it is likely that he underbilled at the ML103 rate. Due to no timely objection, defendant must self-impose a 10% penalty; also, add 7% annual interest from the time the bill became due until it is paid.

I am not aware of any five-hour limitation to psychological testing and I would be grateful if someone would cite a proof source.


Re: PTP Med-Legal Initial Report and TF (California)

PostPosted: Sat Apr 04, 2009 8:29 am
The patinet was referred by the AA, not for QME, only as the PTP.
After looking over the billing, there was some psych treatment billed.
FYI, the report show 5 hours total for Face to Face time, Review of Records and Research.

Here is my thinking:
1. The claimant went tothe AA because his claim was contested by the IC. Now there is a disputed claim.
2. The AA sent him to the psych doctor (PTP)to prove or disprove an injury via report. The report presented the findings and condition of the patient, including test results indicating need for more treatment.
3. The AA is considered a party in the case requesting the report.

Is my thinking process way, way off?

If so, since the IC did not dispute our services via EOR, do I have any grounds to stand-on because of no EOR?


Re: PTP Med-Legal Initial Report and TF (California)

PostPosted: Sun Apr 05, 2009 2:40 pm
by jonbrissman

Your analysis is fine. The only sticking point is whether the AA requested a medical-legal report. Referral by AA to the PTP for treatment does not automatically include a request for a medical-legal evaluation, and the PTP may not decide on his own that such reporting is necessary. Does the PTP have a document from AA requesting a comprehensive evaluation?

Notwithstanding the above, if medical-legal services are appropriate: The physician apparently underbilled at ML103. As you know, if four or more of the complexity factors listed in ML103 are met, then the report qualifies for ML104 billing. Five hours in combination of face-to-face time and records review is two factors, and if the PTP spent at least one hour in report preparation then the six-hour+ combination counts as three factors. Addressing causation is a factor, addressing apportionment is a factor, and a psychological/psychiatric evaluation is a factor. Thus, you potentially have as many as six factors to qualify the report for ML104 billing.

Billing at ML103 yields $937.50 and it is a flat rate irrespective of the amount of time spent. Billing at ML104 is a time-related charge worth $62.50 for each 15-minute segment, so the five hours you mentioned empowers a charge of $1,250.00. Adding the amount of report-preparation time will push the charge higher. I regularly see ML104 charges that include six to ten hours of report-preparation time, making the total ML104 charge in the $2,000 to $3,000 range.

It may be too late to upcode and rebill the services. The body of the report is supposed to contain a "verification under penalty of perjury of the total time spent by the physician in each of these activities: reviewing the records, face-to-face time with the injured worker, preparing the report and, if applicable, any other activities." [8 CCR Sect. 9795, ML104 subsection] A subsequently-issued addendum that contains the information may or may not be acceptable -- I am aware of no case law of the issue, and defendant will likely deny payment at the enhanced rate so litigation will become necessary.

The PTP's staff could have helped more. They should have insisted on documentation requesting a medical-legal report prior to the evaluation; they should have counted the complexity factors so as to bill the report correctly; and they should have checked that the report contained the verification of time required for ML104 billing. Doctors are sometimes clueless on WC procedural requirements and must depend on the knowledge and thoroughness of their staffs to get paid appropriately.


Re: PTP Med-Legal Initial Report and TF (California) (California

PostPosted: Sun Apr 05, 2009 5:17 pm
by postscript2
I think some BASIC points are missing here...

First of all, if the I/W filed a false claim and was under investigation... AND has filed a DWC-1 form--the I/C/TPA/ER still has an obligation to pay for the first $10k in "medical," while the claim is under investigation. The labor code allows this...

The question here is whether it's med-legal or NOT.

Now, I've had several cases like this--when the "defense" will not go the PQME or AME route, if they have a "solid" defense "AOE/COE." Been to trial on a few of these and the defense won. The defense needs not a med-legal report if they intend to "TRY" the case.

None the less, the first $10k in medical is mandatory!!! I've posted this before. I attended a seminar with "Cora Lee," of the Audit unit. It makes no difference what the charges are--they need to be paid, subject to U.R. (which is iffy)... As I heard at the seminar, in 2007, first come, first serve. In other words, the money is owed... AND likely with penalties and interest.

Just pay the darned lien or negotiate and BE DONE! Further, I learned that it doesn't matter what provider, whom sent the I/W to the provider and the amount charged--that's why I say--I think the defense is SOL!

It makes no sense to keep a file open any longer than necessary--it's just not common sense to fight something like this!!!


Re: PTP Med-Legal Initial Report and TF (California)

PostPosted: Sun Apr 05, 2009 8:19 pm
by jonbrissman
As Postscript2 noted, the issue is whether or not the services were validly characterized as medical-legal, and my prior posts addressed only medical-legal issues. But now that L.C. Sect. 5402 and the first $10,000 in liability for treatment has been raised, I'd like to comment thereupon.

Liability for medical treatment accrues only until the time that the employer/carrier/TPA accepts or denies liability for the claim. On disputed psychological claims, the currently common practice is to deny immediately and then continue the investigation. This appears to be a prudent strategy for defendants because it stops the accrual of liability for treatment while keeping open the possibility of accepting the claim after the investigation is completed. So, the comment "the first $10k in medical is mandatory!!!" is accurate only when defendant chose not to accept or deny liability while treatment charges were amassing.

Further, the "false claim" assertion requires more scrutiny. If the claim amounts to criminal fraud, I don't think defendant is liable for either treatment or medical-legal charges. But my experience is that defendant's allegation that a claim is false is generally something less than criminal fraud.

Lastly, defendants who refuse to obtain medical-legal reporting because they think they have a solid AOE/COE defense are fine if they can try the case on the AOE/COE issue only. However, they can get burned if the WCJ sets the matter on all issues and they do not prevail on the AOE/COE issue -- the WCJ then will likely find PD based on the PTP's conclusions and defendant has lost the chance to dispute it.


Re: PTP Med-Legal Initial Report and TF (California)

PostPosted: Mon Apr 06, 2009 7:13 am
Thank you Jon and LCS!

L.C. Sect. 5402 and the first $10,000 should work.

You all work the weekends too!