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

[Manila]

Has any one heard that the Medical Unit and Winslow West are stating preparation/report writing time is now not billable for ML-104's?

[spreare]

No haven't heard. report writing time was never included as a complexity factor though. When you reach four complexity factors the time element is billable, including the report preparation time if the time was expended by the physician.

[cmunday]

I have heard Winslow West present twice. Indeed, his interpretation is that one can bill for report preparation time with an ML104 only if one has written pre-authorization for a 104. He reviews 3 types of 104s or methods to get to an ML104 and that only the third method allows for report preparation. He did emphasize that this was his interpretation of the regulations with the implication (at least to my interpretation) that on review there might be a different interpretation. I personally know one QME who was non-renewed for "fraudulent billing" for billing for report preparation time. Let me issue the caveat that I last heard Mr West present in June and I don't know if anything has changed since then.

[spreare]

This is all fairly bizarre that one DWC employee could just interpret the fee schedule in a manner completely variant to the DWC's own published training guide, not to mention the actual labor codes, etc. Workcompcentral did an article about this in July as I recall. It is all very bizarre and I personally wonder whether some of the information is convoluted -- IE hearsay etc. Sure docs have been non-renewed, but what were the specific circumstances? Maybe if you dug deeper in the cases of non-renewal we would find some dereliction, etc? I certainly hope that is the case because to think that doctors are being non-renewed while being compliant with the medical-legal fee schedule is certainly an enormous due process issue. I have heard all sorts of things about this Winslow West and I have spoken with him on the telephone about one particular case I needed assistance with and e-mailed too-- he was a perfect gentleman and very helpful.
I have heard from other sources that he has told orthopedists that they should not be, or should only rarely be adding medical research as a complexity factor, since their education and training should already incorporate the research they don't need to perform it. I have also heard that some ortho's or other doctors have, or are in the process of, filing a suit against DWC with Mr. West named. I heard that the DWC was going to be sidelining Mr. West, perhaps putting him somewhere else.... Nothing I have heard is anything beyond rumor and maybe none of any of it is true. What is clear, is what is the medical legal training module that is still posted on the DWC sight and has not been replaced or removed. I do not see how any doctor could be non-renewed while complying with the fee training guide. Perhaps there was a large batch of non-renewals and they eventually renewed them... On the grimmer side, usually where there is smoke there is fire. So some amount and manner of injustice against PQME's this last year has likely occurred. Hopefully from now on Wes and or the renewal staff at DWC will abide by the text of their own publication:

https://www.dir.ca.gov/dwc/DWCPropRegs/ ... ations.pdf

[cmunday]

Spreare, please recognize that I am just telling you what I know. I did hear this from Mr. West himself. I refrain from re-broadcasting rumors. My impression is that things have calmed and I wonder what is actually being done with this at present - I don't know. I have my own opinions about all of this but am not going to express them here. Anyone who is concerned about this should take further steps to investigate to reduce the chances of getting into a conflict.

[appliedpsych]

I recall reading something about MD level doctors, such as orthopedic doctors, were getting challenged on some of their ML-104 billings, as the adjustors were saying that the review showed they were still in the ML-103 range.
Unfortunately, I did not make a copy of that document.

I have billed for report writing time in all QME's I have done this year, and was paid, and many of these were before I was successfully renewed in April.

[appliedpsych]

Here is the CURRENT Billing Regs Listing. http://www.dir.ca.gov/t8/9795.html

What you have to do is cite the multiple complexity factors of of ML-103 which make it comply with the ML-104 level. So, on page one of the report a PSYCHOLOGIST can include the ML-103 listing of (8) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation. Here is what my page one typically looks like.

BILLING METHOD: THIS IS A PANEL Q.M.E MEDICAL-LEGAL EVALUATION. THIS REPORT IS BEING BILLED UNDER ML104 OF REGULATION 9795. THIS IS DUE TO THE FOLLOWING QUALIFYING FACTORS:

1) Two or more hours of face-to-face time were spent with the patient.
2) Two or more hours of record review were required.
3) Two or more hours of medical research were required, to examine issues related to the clinical and medical-legal issues pertinent to the case.
4) Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity factors
5) Addressing the issue of medical causation upon written request of the party or parties requesting the report, or if a bona fide issue of medical causation is discovered in the evaluation
6) Complex issues of permanent and stationary status, temporary disability, permanent disability and apportionment were addressed, upon request of the party or parties requesting the report.
7) A complex and comprehensive psychological evaluation which was the primary focus of this medical-legal evaluation.

Now a psychologist has that little extra item 7, other doctors do not. My understanding is that it has been M.D.s other than psychologists or psychiatrists that have had the problem with acceptance on ML-104.

[spreare]

But the issue being raised is that docs are getting in to trouble based on individual interpretation of the fee schedule by West Winslow -- an interpretation that is at variance with the published schedule itself. It was called "underground regulations" I think was the term used in the workcompcentral.com

[mytwocents]

AppliedPsych, it is not proper to claim 1), 2) and, 3) and then also claim 4), that you have included in your typical page 1, in order to give you 4 (much less 6) complexity factors since 1)+2)+3) and 4) are mutually exclusive. If you have 2 or more hours EACH of face-to-face time, record review, and medical research, you get 3 factors (1), 2) & 3)) and you don’t need 4). To give you an example, if you have 1 hour of face-to-face time, 5 hours of record review, and 1 hour of medical research, you have 6+ hours spent in combination and so instead of merely getting one factor under 2), you get 3 factors under 4) but you don’t get both 2) and 4); only one or the other. Since you’re a psychiatrist, it doesn’t matter because you get your 4th factor simply because it’s a psych evaluation, but if you were an orthopedist and if you couldn’t claim any other complexity factor, you would not be entitled to ML-104.

Furthermore, as far as 5) is concerned, the fee schedule no longer allows a doctor to address medical causation if the issue is “discovered in the evaluation.” The only justification is that you have the written request of the party or parties requesting the report. You can see for yourself by following the link in your post.

Additionally, apportionment only counts if the injured worker is P & S with permanent disability AND there is employment by three or more employers, three or more injuries to the same body system or body region, or two or more or more injuries involving two or more body systems or body regions. Since neither TD nor PD is a complexity factor, and neither the complexity nor the request of the parties is a requirement, your 6) does not state a complexity factor without explaining how apportionment applies. Again, this is stated in the fee schedule.

I don’t know anything about underground regulations, but I believe doctors have gotten into trouble for claiming medical causation and apportionment under circumstances that are not allowed by the fee schedule, as well as not listing the time spent in the time-based tasks that you list as 1), 2) and 3), and claiming medical research without providing a list of citations, and excerpts or copies of "medical evidence relied upon," as required by the fee schedule.

That being said, if a doctor is entitled to ML-104, it makes absolutely no sense to deny that doctor payment for the time spent in writing the report. One might as well take the position that judges are being paid to hear trials and that they should use their own time outside of working hours to write decisions.

[spreare]

I am not sure I am following you exactly mytwocents but are you saying you are not allowed to double dip factors? you get those 3 complexity factors you described if you reached 6 hours, but what ever was used to get those 6 hours cannot be used again. Those only give three altogether. Lets say a doc gets 6 hours/ 3 factor/ from combination of face to face, records research ; now he can pull apportionment if applicable or causation if applicable to get 4 factors. in my experience causation is applicable almost always. Apportionment though, that is different and is 50/50. It is either applicable or it is not. But a doc cannot make it applicable just to use it as a complexity factor.