How Are QME's Handling ML-104 Issues (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.

Re: How Are QME's Handling ML-104 Issues (California) (Californi

Postby appliedpsych on Wed Jan 17, 2018 11:44 am

Speare - not much different than that last big changes when IMR got put in place - employer groups lobbied DWC to change QME rules, establish a new system, and bang, bam boom, it happened, and has now survived all challenges. Why would they think that they could not do the same thing now with the whole QME system?

I don't know that would entail conspiracy really, just a well-coordinated organizational change, one which the legislature and courts have approved of and protected.
Last edited by appliedpsych on Wed Jan 17, 2018 12:20 pm, edited 1 time in total.
User avatar
appliedpsych
 
Posts: 374
Joined: Fri Mar 06, 2009 8:31 am

Re: How Are QME's Handling ML-104 Issues (California)

Postby spreare on Wed Jan 17, 2018 11:55 am

I have a separate question I hope someone can answer for me regarding an ML 103 which I performed. There was a moderate amount of medical records which took me two hours to review. I indexed the records, you know, the name of doctor, date, and name of the document, a long list down the page. I remember reading somewhere that QME needed to write a list of the records reviewed. at the beginning of the report, I indicated "two hours of medical records review. I forgot to mention however that there was a certified interpreter present -- there was and the carrier provided the interpreter.

Two things happened that seem to cost me $400 and I want to send to second bill review: 1) EOR paid only for ML 102, stating that a summary of the records is required. 2) they did not pay the interpreter modifier code stating that it was not listed in the report. Can I send this to a second bill review with a signed statement under perjury that there was, in fact, an interpreter, and again sign under perjury that two hours spent in the MRR? I do not think I can include the summary of records in the second bill review if it was not included in the initial PQME, but maybe I am wrong? I really do not even think ii need a summary, just a list, and signed statement. Any advice? Thank you!
spreare
 
Posts: 575
Joined: Fri Mar 13, 2009 9:02 pm

Re: How Are QME's Handling ML-104 Issues (California)

Postby concernedcitizen on Wed Jan 17, 2018 1:53 pm

Spreare, it's interesting that you are having this issue.

On issue #1: The carrier is not recognizing your record review time because a "summary of the records is required." The regulation that states what is required in your QME report is 10606. https://www.dir.ca.gov/t8/10606.html.

Here is the relevant section: (4) a listing of all information received in preparation of the report or relied upon for the formulation of the physician's opinion;

On the main topic of the QME witch hunt and the DWC's audits, I came across a QME's reappointment denial letter recently which indicated, amongst other alleged offenses, that the QME erred in using the record review complexity factor because the record review appeared to be a verbatim synopsis of the medical records. It was not. The DWC auditor reasoned that since the doctor's record review was excessively thorough, he should get credit for 0 hours of record review and not be entitled to that complexity factor. That took the report (which took over 10 hours to prepare) down from an ML104 to a lesser code. The DWC is getting more creative with its rationale for downcoding various reports. Virtually all the reports that the DWC downcodes from ML104 were paid as ML104 by the insurance carrier. The controversy manufacturing machine is working overtime.

On issue #2, the interpreter issue, I would recommend getting the name and certification number for interpreters involved in future evaluations and including that information in your report. It certainly can't hurt to try your luck with SBR.
concernedcitizen
 
Posts: 7
Joined: Fri Sep 29, 2017 1:57 pm

Re: How Are QME's Handling ML-104 Issues (California)

Postby DrDoc on Wed Feb 07, 2018 12:49 pm

Article on main sight today describing Judge determining that QMEs had been denied timely hearing and underground regulations had been relied upon apparently. Have not been able to download article. Repeated Messages about checking my email to update, but no email arrived. Looks promising though.
DrDoc
 
Posts: 57
Joined: Fri Oct 04, 2013 1:11 pm

Re: How Are QME's Handling ML-104 Issues (California)

Postby spreare on Wed Feb 07, 2018 10:04 pm

I wonder what the blow-back could be for the DWC being chastised by a superior court judge. Seems like the medical unit has been in very poor form with respect to this issue.
spreare
 
Posts: 575
Joined: Fri Mar 13, 2009 9:02 pm

Re: How Are QME's Handling ML-104 Issues (California)

Postby jobmdpsych on Fri Feb 09, 2018 8:58 am

I read the article. It's a start but certainly not everything we want in terms of due process. 90 days is enough to cause real havoc in one's practice.

There's a simple solution really, just don't pay billing for dubious services like research unless the justification is documented. Frankly, if you routinely bill for research, you are asking for trouble and will find it. If the QME keeps doing it, write them a letter to knock it off. But cutting off QME status and accusing people of crimes before a hearing is a clear violation of due process.
jobmdpsych
 
Posts: 315
Joined: Sun Jun 28, 2009 7:28 am

Re: How Are QME's Handling ML-104 Issues (California) (Californi

Postby spreare on Fri Feb 09, 2018 9:39 am

IMHO this requirement for 90-day hearings derails the entire process the medical unit is engaging in. They are not going to be able to get the volume of hearings by that time frame and in any case it takes away their authority in the sense that they can accuse whoever whatever they want but It's up to a judge to decide. I think it brings the system to close to what it should be. It is the medical unit's job to be a prosecutor against bad QME players, but the swift due process mechanism checks their previous usurpation of the process. This will for sure from now on cause them to re-think who they are going to non-renew.


Edit: and regarding the misuse of medical research, i understand the gripe but I the problem is when someone gets a bankers box of records, that does does not want to be paid $10/hour. So I think what some docs are doing is doing research to get the component in to be paid fairly. Perhaps they need to tinker with the ML fee schedule to be fair all around so a doc does not get a banker box of records and not able to be paid for the time to review.
spreare
 
Posts: 575
Joined: Fri Mar 13, 2009 9:02 pm

Re: How Are QME's Handling ML-104 Issues (California)

Postby jobmdpsych on Fri Feb 09, 2018 11:06 am

I hope you are right. This reminds me a bit of the 2013 QME backlog...so if they can't do it in 90 days, basically they can't do it all unless they start picking their battles more carefully.

On the other hand, billing for research routinely is not picking battles carefully. If you are hired as an expert, this shouldnt be necessary on a routine basis. Billing for research is poking the tiger and asking for trouble. I strongly disagree that it should be a behind the back compensation for review of records. I bill for my time honestly for review or records and I generally do not have a problem. The real problem with review of records is that since they went electronic, no one at the law firms bothers to cull them as they did when they were paper.

BTW since the DWC is concerned about billing disputes I'd like to see them start cracking down for nonpayment of missed or late cancelled appointments, which providers are entitled by law to be compensated for. The issue of billing fraud (or really negligence) works both ways.
jobmdpsych
 
Posts: 315
Joined: Sun Jun 28, 2009 7:28 am

Re: How Are QME's Handling ML-104 Issues (California)

Postby spreare on Fri Feb 09, 2018 12:52 pm

I think i disagree with your hard take on research. It is there is in the fee schedule without restrictions. I mean, I agree that it should be relevant but that is the only restriction that I think should apply based on the way the fee schedule is written. To start splitting hairs with docs about research -- well I just do not agree with that. Really i think they should do away with all the formatting and just pay a straight hourly rate. That is how experts are generally paid.
spreare
 
Posts: 575
Joined: Fri Mar 13, 2009 9:02 pm

Re: How Are QME's Handling ML-104 Issues (California)

Postby spreare on Fri Feb 09, 2018 1:04 pm

By the way, did you read the court opinion? Pretty cool actually. It is too large to upload but the 25 page decision is a real lesson in public law.
spreare
 
Posts: 575
Joined: Fri Mar 13, 2009 9:02 pm

PreviousNext

Return to Legal

Who is online

Users browsing this forum: No registered users and 3 guests