AME & Lien Question (California) (California)

This category is meant for discussion of technical legal issues in workers' compensation. If you are an injured worker, do not ask questions here. Go to the Injured Workers' forum.

AME & Lien Question (California) (California)

Postby laesquire on Fri May 29, 2009 8:37 am

SCENARIO:
1. PTP racks up a very large bill. Applicant did have a wrist surgery-carpal tunnel.
2. AME says most of the treatment was not needed.
3. Case settles C&R based on AME which gives Applicant a fair amount of PD.
4. The Defense starts to adjust the liens. Next a pharmacy lien shows up for $ 50,000 plus. The prescriptions were issued by the orthopedic PTP.. The pharmacy did bill per fee schedule.

QUESTIONS:
1. Can the Defense get an admissable supplemental opinion out of the AME regading if the prescription medications were reasonably required to cure or relieve the effects of the industrial injury? If yes, does the defense have to get the lien claimant to agree on the Joint AME letter?
2. Any other ideas on disputing the excessive pharmacy lien?
:o
laesquire
 
Posts: 58
Joined: Mon Mar 02, 2009 10:13 am

Re: AME & Lien Question (California) (California)

Postby steve appell on Fri May 29, 2009 9:29 am

Hi LAE:
Re question #1
You may get an admissable Supp AME from the doc as long as the lien claimant signs the joint letter. If the lien claimant does not sign, you may then get an admissable def report from the same doc.

Re question #2
The answer is yes, but more info is needed.
IE:
types of meds prescribed?
brand and/or generic?
amt of charges?
repackaged?
prepackaged?
med reports deliniating meds?
prescriptions avail?
etc etc etc
Steve

appellandassociates.com
6311 Van Nuys Bl #480
Van Nuys, Ca 91401
wcexaminer@aol.com


Check out 'WORK COMP MATTERS" Free PODCAST below
https://www.workcompcentral.com/educati ... ype=online
User avatar
steve appell
 
Posts: 461
Joined: Mon Mar 02, 2009 12:02 pm

Re: AME & Lien Question (California) (California)

Postby rider001 on Fri May 29, 2009 12:31 pm

Depending on the nature of the denial 4600.2 could come into to play. If this is the case i would offer the contracted rate for pharmacies which around 10% of what medicare allows.

What does UR say about meds? No UR no AME supp. Sandhagen.
Billed at fee Schedule?
ACEOM/ODG?

I have never seen a pharmacy bill for $50k and i have worked for over prescribing orthos in the past.
rider001
 
Posts: 151
Joined: Tue Mar 10, 2009 10:20 am

Re: AME & Lien Question (California) (California)

Postby steelmanlaw on Fri May 29, 2009 2:01 pm

Steve Appell: What you say is the safer route, but not necessarily the only way. Assuming UR was not an issue (based on timing, whether self procured, etc.), there's no legal reason why the lien claimant must sign a joint letter. Under 4062.3, defendant merely needs to copy A/A (and by extension the effected lien claimant) when communicating with to the AME, post DOE.

However, it may be more effective or persuasive to both the lien claimant and/or judge at trial to have jointly-signed letter/interrogs and bills submitted to the AME. MORAL: Sometimes a little politicking above/beyond what the law requires at minimum, wins the day.

But that's just me.
steelmanlaw
 
Posts: 115
Joined: Mon Mar 02, 2009 10:34 am

Re: AME & Lien Question (California) (California)

Postby steve appell on Fri May 29, 2009 3:21 pm

Hi Rider:
Represented parties that want to go to an AME can go to an AME anytime regardless of any other issues, and I encourage you to quote anywhere in Sandhagen, or any case or statute law for the matter, that indicates otherwise. IMHO, you will not find it.

Hi Steelman:
With all due respect, an AME is just that, "AGREED." A lien claimant must agree to the post OACR AME exam and/or report for it to be an AME Report. Otherwise, it is simply a defense report. Also, your reference to 4062.3 of course infers that both parties already agreed to the AME doc which is not the case here. Lastly, lien claimant's are responsible for their own discovery, and are not committed to using the same AME as picked by A/A. However, they are bound by the contents of medical reports already generated unless rectified by depos,interrogatories, supp exams etc.
Steve

appellandassociates.com
6311 Van Nuys Bl #480
Van Nuys, Ca 91401
wcexaminer@aol.com


Check out 'WORK COMP MATTERS" Free PODCAST below
https://www.workcompcentral.com/educati ... ype=online
User avatar
steve appell
 
Posts: 461
Joined: Mon Mar 02, 2009 12:02 pm

Re: AME & Lien Question (California) (California)

Postby steelmanlaw on Fri May 29, 2009 4:37 pm

other than fairness, any legal authority for that position? i'm always willing to learn; keeps me young.
steelmanlaw
 
Posts: 115
Joined: Mon Mar 02, 2009 10:34 am

Re: AME & Lien Question (California) (California) (California)

Postby rider001 on Fri May 29, 2009 4:48 pm

Steve-
Key words "Any parties who want to go to an AME can go."

My point is how are you going to get the lien claimant to agree? Why would any astute lien claimant want to go to an AME who has already stated that treatment wasnt reasonable. Why would any lien claimant want help disprove necessity? If UR timeframes were not followed and AME has commented on it yet what benefit is it of the lien claimant to go to
AME? Unless they were confident their 50k worth of medication would be found necessary. I dont think so. Each party will end up getting their own report.

LA E
Does the IC have a PBM (pharmacy benefit manager)? If IC has PBM and billing wan't submitted thru the PBM 4600.2
Is the pharmacy contracted with the PBM? Probably not, if they were it should state all script are to go thru PBM. If not contract can be voided.
Is the pharmacy part of the MPN?
Is their a finacial relationship between PTP and pharmacy? There has to be 50k in meds. Come on.

Again if their is a PBM i would offer to pay them at the contracted rate for pharmacies which is 90% lower than medicare rates unless these were all Brands
rider001
 
Posts: 151
Joined: Tue Mar 10, 2009 10:20 am

Re: AME & Lien Question (California) (California) (California)

Postby jonbrissman on Fri May 29, 2009 7:49 pm

Although Steve works for the defense, he gets it. Everything he said was correct.

A writ-denied case is on point: SCIF v. WCAB (Dr. Roback) 57 CCC 509 (2002). It says that the opinions of an AME are not binding on a lien claimant when the lien claimant did not participate in the selection of, or agree to, the AME. Writ-denied cases are not precedent but judges often find them to be persuasive when they consider the same issue.

Lien claimants recognize that the only reason a defendant wants to obtain a supplemental opinion from a physician who once was an AME is that defendant wants to escape liability for some or all of a lien claimant's charges. Generally, it is not in the lien claimant's best interests to cooperate with defendant.

Defendants need to make an honest cost-effectiveness analysis about seeking a supplemental report from the prior AME. Factor in the cost of the report, the additional interest that will accrue while the parties wait for the report, the possibility that the report will not reduce defendant's liability, and the possibility that the liability is reduced by an amount less than the cost of the report. In my experience, the strategy has seldom turned out to be successful.

I know of one lien claimant that regularly cooperates with defendant's request to return to an AME for a supplemental report. This lien claimant then sends the AME (with copies to defendant) several thousand pages of evidence-based medicine studies supporting the particular services provided, thus increasing the likelihood of obtaining the AME's support while insuring that the charge to defendant for the supplemental medical-legal report will be in the thousands of dollars (which is usually more than the amount of the lien at issue).

JCB
User avatar
jonbrissman
 
Posts: 391
Joined: Mon Mar 02, 2009 5:43 pm


Return to Legal

Who is online

Users browsing this forum: No registered users and 2 guests

cron