How flexible is 4062(a)? (California)

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How flexible is 4062(a)? (California)

Postby cmc1959 on Fri May 29, 2009 11:47 am

Hello, and thanks in advance for your time and consideration of this post...

UR for therapy has been requested by the PTP and denied by the carrier. The PTP appealed according to the carrier's rules, and the services were again denied.

No objection was filed by the ee, but rather, the PTP scheduled a "med-legal evaluation" with himself (allegedly at the request of the claimant), and produced a med-legal report detailing why therapy was needed. The carrier denied the bill for the med-legal report, telling the provider that it was improper to perform the evaluation as the PTP since rule 4062 specifically requires the claimant to object to the denial and then have an AME do an independent evaluation.

The claimant's attorney asserts that the provider is allowed to submit a rebuttal to UR decisions that are "cursory, inaccurate and confusing." I thought a rebuttal could be submitted in response to a QME report, but not in response to an appeal outcome - or in lieu of a QME.

The provider has been notified that he is doing a disservice to his patient and a request was made that he cease performing med-legal evaluations for the purpose of disputing UR denials. He insists that his report is 'admissible' but has not pursued any action under which his report would be reviewed, let alone admitted.

Are the provider's actions proper or allowable in this situation?
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Re: How flexible is 4062(a)? (California)

Postby jakelast@aol.com on Sat May 30, 2009 12:50 pm

This is probably a combinationof both allowable and unallowable activity.

The PTP is allowed to generate a medical legal report to address a disputed issue and clearly the denial of Tx results in a disputed issue. However it does not replace the obligation on the part of applicant to object to the UR determination and proceed under LC 4062. The PTP's report is not a 4062 report but a treating physicians report and is admissable. Once the qme report on the UR issue is received, there is no longer any rebuttal allowed (See Willette v AU Electric) from either the PTP nor the UR doc.

However I do not think the scheduling of a "medical legal" exam to address the UR issue is justified. There is no reason for the PTP to conduct and examination and take a history from the patient where he presumably has already done that to justify the recommendation for treatment. If he billed for a full eval under the medical legal fee schedule, the PTP is trying to rip you off. A simple supplemental report giving his response to the UR determination is all that is needed for this one issue report. Such a report could reasonably include review of evidence based medical guidelines to support the recommendation but the exam part is bogus. I would recommend you pay the reasonable value of a supplemental report, at the medical legal rate, and deny the remainder.
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Re: How flexible is 4062(a)? (California)

Postby cmc1959 on Sun May 31, 2009 1:17 pm

Thank you for your thoughtful response and the referral to the Willette case. If I understand correctly, the provider can rebut the UR decision - presumably with the intent that the rebuttal will be reviewed as part of the dispute - and provided that the rebuttal is completed prior to submission of an AME report. Assuming this is correct, I have two points needing clarification:

1 - If the report is necessary to address a "disputed medical fact", the Administrative Rules appear to consider this a med-legal expense. But a report that doesn't include a med-legal evaluation "shall be subject to the Official Medical Fee Schedule adopted pursuant to Labor Code Section 5307.1 rather than to the fee schedule". So is that type of report still a med-legal expense? And what authority (other than logic and common sense) excludes the PTP from performing a full examination? In other words, what rationale would be used in objecting to a portion of the charges? Is this a simple bill-review matter?

2 - Would it be accurate to expect that a supplemental report would only be needed in the event that the injured worker objected to the UR denial? And conversely, if the claimant doesn't object, would there be any reason to prepare a rebuttal?

Thank you again for your time - it is very much appreciated!
~Chris
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Re: How flexible is 4062(a)? (California)

Postby stevepsca on Sun May 31, 2009 1:57 pm

Hi Chris...
It looks like this is becomming more difficult than need be.

The PTP writes a request for treatment, that goes to UR for determination to medical necessity.
If I understand correctly, the provider can rebut the UR decision - presumably with the intent that the rebuttal will be reviewed as part of the dispute -(close...) and provided that the rebuttal is completed prior to submission of an AME report.(I think this is where some confusion may be...)
The UR process must be exhausted prior to a 4062/AME evaluation.
During the UR process... PTP doesn't 'refute' the UR decision, but appeals if necessary.
Generally, the UR doctor will contact the PTP for additional information, If a written narrative is necessary, the PTP will provide that including the additional EBM to back up the request.
LC 4610(d)http://www.leginfo.ca.gov/cgi-bin/displaycode?section=lab&group=04001-05000&file=4600-4614.1

Only if the UR denies on a PTP appeal, would the IW/AA need to initiate the 4062 process and utilize a PQME/AME
There is no PTP 'med/legal' report. The PTP doesn't self appoint/schedule a med/legal exam. There is no need for additional examination for a request for treatment through the UR process until the 4062 dispute resolution is requested.

My understanding has always been a party must request a medical/legal evaluation/report from a PTP and/or PQME/AME as the case may be. Supplemental would be the same ....

The Title 8 CCR is here...§9792.6. Utilization Review Standards. http://www.dir.ca.gov/t8/9792%5F6.html, probably gives a better definition of the process than I can.

No objection was filed by the ee, but rather, the PTP scheduled a "med-legal evaluation" with himself (allegedly at the request of the claimant), and produced a med-legal report detailing why therapy was needed.
Is this PTP in a MPN ?
"therapy'',....PT ?. Has the 24 visit cap been reached by the IW ?
If so, none of this is relevant...only the ER/CA can authorize additional PT/OT/Chiro beyond the cap. No M/L, no 4062 is necessary...
If MPN, s/he should be familiar with the UR process/plan the ER/IC has in place. And know that med/legal is not the appropriate step...other than attempting to bill for a M/L report w/o justification.
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Re: How flexible is 4062(a)? (California)

Postby cmc1959 on Sun May 31, 2009 2:26 pm

Hi Steve - thanks for your input. Everything you said makes sense to me, and I agree - it seems more difficult than it needs to be. The problem is that the PTP is getting back-up from the IW's attorney as well as members associated with the California Society of Industrial Medicine that he is acting appropriately. Just to backtrack a moment.....

The 24-visit cap is not an issue here. All this has taken place subsequent to UR denying the appeal. There is documentation that the claimant requested the med-legal evaluation with the PTP (a form letter the PTP had the claimant sign). And yes, the PTP is in the MPN.

I actually work for the MPN, and received this scenario in the form of a complaint the carrier filed against the provider. I attempted to educate the provider, but he insists he is entitled to perform and bill for a med-legal evaluation. I informed him that his participation in the MPN was in jeopardy if he was going to continue using these evals to dispute a UR denial, and then I received a letter from the claimant's attorney stating the report is admissible.

I can see by a slim stretch how it would be - so long as it's not being submitted as a 4062 report, and IF the claimant had filed an objection. But she didn't - therefore, it seems to me the report would be moot on top of being excessive (referring back to Jake's observation about the H&P.)

I'm just looking for some clarification of the rules so that I can be sure I'm on solid ground when corresponding to the doctor - as well as the carrier.
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Re: How flexible is 4062(a)? (California)

Postby rider001 on Mon Jun 01, 2009 8:44 am

This sounds more like a fee schedule issue than anything. PTP can write ur disuptes upon the request of the IW or their attorney. Whether the ML gets paid at an ML rate or at the appropriate reporting rates in entire up to bill review.
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Re: How flexible is 4062(a)? (California)

Postby cmc1959 on Mon Jun 01, 2009 10:22 am

I believe you are right. I was approaching this problem under the premise that the doctor was attempting to submit this report as an alternative to filing a dispute (as if he were acting in place of an AME). But looking at it from the perspective that he is preparing the report in anticipation of a dispute, then what he is doing makes some sense.

I don't know why the ee never filed a dispute, but at this point it is not my concern. I'll leave it to the carrier to duke it out with him about payment for the "service".

Thanks for all the feedback and helping me process this through!
~chris
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Re: How flexible is 4062(a)? (California)

Postby vampireinthenight on Mon Jun 01, 2009 3:00 pm

Although probably up for debate, I always assert that the PTP supplemental report is inadmissible. LC 4062(a) specifically states that the AME/PQME process shall be initiated and no other reports shall be obtained.

In short, you get the original PTP report, the UR report and ONE med-legal, that's it. The legislature clearly wanted to limit the med-legal reporting to one when they revised 4062.
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Re: How flexible is 4062(a)? (California)

Postby steve appell on Mon Jun 01, 2009 3:21 pm

And what authority (other than logic and common sense) excludes the PTP from performing a full examination? In other words, what rationale would be used in objecting to a portion of the charges?


Based on your fact pattern and Jake's analysis, I would object to the exam charges under LC 4064(a).
IE: The exam is not reasonable.

Good Luck !
Steve

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