If you don't want a five figure bill, don't send 5000 pages

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If you don't want a five figure bill, don't send 5000 pages

Postby jobmdpsych on Thu Jan 17, 2019 12:38 pm

of records.

A King James Bible is 1200 pages. It is completely ridiculous to ask a doctor to review four Bibles and look within them for needles in haystacks, then complain relentlessly to bill review and the DWC about large record review costs. It's also ridiculous to expect the doctor to absorb that amount information and answer for it in a deposition.

Twenty years ago this rarely happened when records needed to be boxed and shipped. It was too inconvenient so the records were culled to eliminate the chaff and clutter.

Today, it's just too easy to email a massive PDF file.

Look, I don't want to review that many pages, and I don't think the carrier wants to overpay. I'd rather not have the money for the aggravation. Two inches of records should do it in most cases. I implore firms to please cut down the records to only that which is necessary. It's much cheaper to have assistants at the firms do this than to dump it onto doctors.

Document dumping then whining about the costs of it isn't on us, that's on you. We can't make this problem go away but the firms and carriers can.
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Re: If you don't want a five figure bill, don't send 5000 pages

Postby jpod on Fri Jan 18, 2019 8:52 am

That certainly sounds excessive. I think you are right that digital access to records is a contributing cause.

However some of the cause is the change in the law on apportionment. Before there had to be disability so if one couldn't prove a past disabling event medical history was mostly irrelevant. If you pay WC premiums you expect the insurer to only pay what the law says is owed on the claims related to your coverage though.

We may be headed to a solution where medical opinions aren't needed to determine PD - that strict loss of earnings and some sort of table that incorporates body part, occupation and age to calculate PD for a claim (much like the old PDRS without the medical component). The history of WC in CA is littered with examples where the tail wagged the dog, which led to legislative action, that led to disruption to the economic landscape for the vendors operating in the system.
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Re: If you don't want a five figure bill, don't send 5000 pages

Postby LawAdvocate on Fri Jan 18, 2019 9:30 am

Unfortunately, what you consider document dumping, is not. Number one, we aren't physicians, how many times have we sent records and found out that one condition was causing part or all of the industrial issues? Or a hundred other situations that only a physician would catch. You are relying on people being capable of giving you complete and accurate medical histories. My own mother can't do this.

Number two, your reports MUST be substantial evidence, which goes back to number one, you have to review all of the pertinent medical records in the matter. If your report does not meet this standard, it is inadmissible. So back to number 1, we are not physicians we do not always know what is pertinent and most of the time we can't risk getting your report thrown out. It delays the case and causes actual harm to injured workers.

Number three, some injured workers have multiple cases, those cases require apportionment, so if you have multiple prior workers' compensation cases, 5000 pages is light.

If you don't want to review records, don't do medical-legal examinations. The doctors should be paid, it is not like the carriers or self-insureds are really suffering - look at the recent numbers. I would prefer that injured workers get actual treatment.

QMEs can in fact demand a paper copy and are not required to accept records on CD. It's buried in the CCRs somewhere.
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Re: If you don't want a five figure bill, don't send 5000 pages

Postby jobmdpsych on Fri Jan 18, 2019 5:54 pm

The key word that you wrote was "pertinent". Some cases require 5000 pages. Very few. There is no reason to send patient instruction sheets, records of toe fungus treatment in 1993, or anything not germane to the medical opinion being sought.

I think we can agree on that. A paralegal ought to be able to weed that out and save the carrier some money.

Doctors in busy practices simply cannot take five days to review records on a case, realizing later on that four of those days were wasted. This is a tremendous drain of time and money. Then they fight to get paid for their aggravation. We wonder why QMEs are quitting, this is why.

I'm reaching out, asking law offices to be discrete, so that we can bill less and be less encumbered.

It's not like insurance companies won't raise hell about a five figure bill, they do it routinely regardless of the number of records. This puts us in a bind. This is what they do, regardless of what the quarterly profit statement shows.

"you have to review all of the pertinent medical records in the matter"

If you are giving most QMEs thousands of pages of records to review, they aren't really doing it. They're farming it out to third parties to condense and type. I have never done that but many offices I know do just to be able to cope with the load. So it's not like you're getting an actual review anyway. They're not complaining because they're not doing the work and using the difference between document review services and insurance fees as a carry trade.

LIke I said, we can't solve this problem, we're just caught in the crossfire.
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Re: If you don't want a five figure bill, don't send 5000 pages

Postby LawAdvocate on Mon Jan 21, 2019 9:14 am

Again, pertinent is indeed the key word and no one is going to let a random defense paralegal weed out the records, they are not medical professionals. The Applicant has a say as well and Applicant attorney paralegals do not have the time to weed out the records, we don't get paid for it and defense does.

So it isn't going to work. If the insurance company is not paying you that is a whole other issue. When I was an examiner I paid all of my bills daily, including the medical-legal bills.
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Re: If you don't want a five figure bill, don't send 5000 pages

Postby jobmdpsych on Mon Jan 21, 2019 12:11 pm

So maybe what needs to happen is that the defense firms meet with the carriers and explain the value of the additional service. It's going to be cheaper for them to pay a paralegal than a doctor. If AA doesn't sign on, I agree that it's an impasse. But you have to realize that carriers are complaining about bills that doctors really have no power to reduce, unless they underbill their time. You can't keep the lights on doing that. I know plenty of QMEs who have quit or not renewed because they were honestly billing for their time and then got hammered by the regulators.

There has to be a recognition that beyond a certain volume of information, the stuff is just being skimmed or farmed out. I don't think you want us to be like legislators who vote on bills like ACA ("we have to pass it to find out what's in it") and SB863 routinely without reading them. I don't know how that ever became acceptable.

Going back to my four Bibles thesis, can you imagine a deposition where the doctor got grilled on who begat who in Chronicles 1? Of course, we're not going to know that, we'll know Adam and Eve and the Ten Commandments but no human being can remember or understand all the details. We're people, not hard drives.

The other thing I know is that twenty years ago, two or three inches of records and $2500 bills for complex cases were common for typical cases. It was only the rare 20 year "bucket case" that led to five figure billings. There is no reason a routine case has to be so expensive today. The whole point of SB863 was to reduce frictional costs.
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Re: If you don't want a five figure bill, don't send 5000 pages

Postby DrDoc on Tue Jan 22, 2019 6:24 pm

I don’t think there is any reasonable way to get around the need that the evaluating doctor review the medical records, no matter how voluminous. It seems to me that only the doctor can determine what is pertinent and what is not. It wouldn’t be sensible to expect anyone working in a law firm to understand what “nonpsychiatric“ medical illnesses, medications, life events, etc., may or may not, have relevance in assessing psychiatric diagnoses and the other elements to be addressed in psychiatric evaluations.

I, myself, never accept medical records in digital format. I find it far more cumbersome and difficult to navigate. Regular paper records can be visually scanned, sometimes quite quickly. 100 pages of physical therapy notes, dietitian notes, boilerplate documents, and the like, can generally be thumbed through. I was surprised to find out that we have the right to refuse the digital format in favor of paper. I do have to deal with the pangs of environmental concern though. I also find the process of Med review generally tedious and boring, but we are at the doctors, and we really are reimbursed quite well.

As far as having to deal with “whining”, and going back and forth trying to get paid by the carrier, I simply don’t engage in it. My office provides complete and timely itemized bills. If the carrier refuses to pay for good faith work, after a period of time, I turn it over to my lawyer. After being contacted by my attorney, the carrier pays. Not only is the entire bill paid, but there is additional payment for fines and interest. Also the attorney fees are completely paid for by the carrier.
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Re: If you don't want a five figure bill, don't send 5000 pages

Postby jobmdpsych on Tue Jan 22, 2019 8:46 pm

"It seems to me that only the doctor can determine what is pertinent and what is not."

Under that logic, the attorney would be required to send every medical record since the claimant's birth and every internet posting by and about the claimant.

Actually some social media information about the claimant would probably be more useful than old medicals but we seldom get that.

There is a point and which it becomes absurd, and sanctimony about the purity of record review is not a sufficient response.

There also is a practical breaking point in terms of wrecking the doctor's schedule and this is why many QMEs are dropping out.

In many groups, the doctor never sees the original records and they are summarized by third parties, so the purity argument doesn't hold in real life anyway.

Anyway, congratulations on your willingness to endure pointless tedium. I'd rather not have the money and live a more meaningful life.
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Re: If you don't want a five figure bill, don't send 5000 pages

Postby DrDoc on Wed Jan 23, 2019 6:58 am

Sometimes, such as when a professional loses the ability to present an internally logical argument, the best recommendation is retirement.
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Re: If you don't want a five figure bill, don't send 5000 pages

Postby LawAdvocate on Wed Jan 23, 2019 2:30 pm

Social Media? More often incorrect than not. It lacks no foundation for evidence and does not meet any scientific requirements for evaluating a patient. Are you kidding?

I had that case a few months ago, guess who was involved in the activity the defense accused my Applicant of doing? The Applicant's adult daughter. I rarely see social media evidence that has been authenticated.

I agree with Dr. Doc, only I am going to say it more bluntly - if you don't like the system, get out - your aren't helping anyone when you don't want to do the job and you have yet to figure out how to get yourself paid.
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