Panel QME denied payment (California)

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Panel QME denied payment (California)

Postby rider001 on Wed Oct 21, 2009 2:41 pm

When a panel QME is denied payment for their services what are the remedies? I thought i remembered a threat stating a DOR could be filed prior to resolution of the case in chief to enforce payment. Thought? Citations?
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Re: Panel QME denied payment (California)

Postby jonbrissman on Wed Oct 21, 2009 6:16 pm

For uncontested medical-legal charges, you may file a petition for benefits under L.C. Sect. 4622 prior to the resolution of the case-in-chief. See Otis , et al. v. City of Los Angeles, et al. (1980) 45 Cal. Comp. Cases 1132, and the dozens of cases that cited the Otis decision with approval. Otis is still good law.

A few years ago, WCJ Pam Foust advised the other WCJs during their training sessions that they had the authority to issue orders to pay medical-legal expenses prior to case-in-chief settlement. Nevertheless, WCJs often defer action on a petition for a medical-legal fee payment order, and lien claimants have no right to file a Declaration of Readiness on the issue (see 8 CCR 10770.6).

File your lien (if you have not already done so) and a petition. then hope for the best. If nothing happens, make yourself content with the thought that the principal is increasing by the 7% annual interest while defendant dithers.

JCB
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Re: Panel QME denied payment (California) (California) (Californ

Postby appliedpsych on Thu Oct 22, 2009 2:58 pm

JCB and others - Can you clue me (and I am sure others) in on this issue?

I have never had this happen, but do hear of it from time to time, and of course would like to avoid it happening to me.

A Panel QME is a formal legal process, resulting from a State Panel list, lawfully requested by appropriate parties, as in a Strike Panel, or by the Injured Worker, or by the Insurance Company.

A formal referral letter authorizing the Panel QME is usually sent to the QME by the attorney parties, or the insurance company. The letter contains not only the admission that the QME is authorized to perform the evaluation, it almost always contains referral questions for the QME to answer. In fact, if I do not get such a letter by several weeks before the QME appointment, I call and demand one, even if it is only a one or two sentence authorization from the insurance company.

Once all parties know about and agree to the Panel QME, and it is PROPERLY SERVED, by what statutes, rights or reasons can Panel QME payment be denied? By whom is it denied? What are the appropriate reasons that payment for a true Panel QME be denied?

Let's face it, If insurers could just refuse to pay Panel QME fees, none of us would ever get paid. If all parties (QME included) followed the laws to the letter and payment was routinely denied, why would any QME's remain?

To date, I have never missed getting a payment. I've never had to file a lien. I have had to reason with claims examiners and sometime their supervisors and point out the statutes to them, and a time or two I had to send them a copy of the complaint I planned to file with the Audits Board if payment was not forthcoming. After that, I have always gotten the payment, and sooner or later, the penalties and interest, as mandated by the Labor Codes.

Nine times out of ten, the inappropriate denial problem began due to an inexperienced claims adjuster, or a bill review company employee who did not know the difference between a Medical-Legal Panel QME report, and a treatment generated report performed by a QME under different auspices than a true Panel QME.

Once the claims examiners and the bill review company understand the distinction and the penalties for improperly denying payment for a Panel QME, they pay up post-haste.

Am I missing something? Is the originator of this post referring to a report performed on the basis of a referral by a treatment source, and thus a medical-legal treatment related report, but not really a PANEL QME? I have heard of plenty of those getting denied.

I have also heard of reports being denied due to a technical error by the QME. For example the QME can forget to follow the proper technical procedures, such as stating at the start of the report the justification for the ML level billed, and at the end posting all required Physician Affadavit swearings.

I just do not understand how a true Panel QME can be denied payment as they are an integral part of the WC process.
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Re: Panel QME denied payment (California)

Postby rider001 on Thu Oct 22, 2009 4:16 pm

I was reffering to a true Panel QME. Not very often but it happens.
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Re: Panel QME denied payment (California)

Postby jonbrissman on Thu Oct 22, 2009 4:37 pm

Essentially, this is a contract law situation. When QME services are authorized, the only basis for defendant's failure to pay is breach of contract by the QME. If the report is unusable, perhaps because the physician recorded a false and inaccurate history or omitted the elements in 8 CCR 10606, defendant will have no liability. There are some correctable oversights, such as failure to include the Section 4628 declarations. Extreme untimeliness that causes another QME to be contracted will dissolve liability, but slight untimeliness is usually waived.

Employment and coverage are the only absolute defenses to medical-legal charges, but even those won't work if the services are authorized: The liability is contractual.

I saw a QME report this week that found injury but no disability and no subjective or objective findings -- yet it then apportioned 20% to non-industrial factors. Silly, but the report is still compensable because the apportionment statement was superfluous and therefore irrelevant.

A non-compensable QME report is a rarity. The vast majority of unpaid medical-legal billings are due to defendant's indolence or ignorance. But if claims adjusters and defense attorneys always did the right thing, I'd be out of business.

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Re: Panel QME denied payment (California)

Postby appliedpsych on Thu Oct 22, 2009 6:44 pm

Thanks Jon - now I get it, and I fell better hearing your opinion.

At least it does not seem to be just a whim or oppositional behavior because they did not agree with what the report said, which I thought was the issue - some QME's have implied that to me. Instead it has to be a major defect of some kind in the denied report, with some exceptions for ignorance that you pointed out. I will continue to be very cautious in making sure I dot the i's and cross the t's in my reports, now that I have read your points.

Rider - are you willing to share the reasoning of the IC in refusing payment on the one you're referring to?

Just might help save someone elses bacon in the future.

I have always found that talking to the claims examiner or supervisor can unstick some problem situations, so maybe try that. I would not use any staff to do that though, but talk you to the examiner yourself directly as it carries much more weight.
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Re: Panel QME denied payment (California)

Postby rider001 on Tue Oct 27, 2009 8:50 am

Applied-
The case/s i was inquiring about are not mine but i am looking into them for a friend. When i have more information i will post although it might be some time before i will get to and complete my audit of those accounts. All i was told was they are psych panels.

I do remember one years ago where the IC tried to say the doctor was of the wrong specialty. Doc was a toxicology and chemical exposure specalist and IW had a chemical burn with nuerological complaints due to chemical exposure.

You are right usually just takes a stern talking to, to get paid.
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Re: Panel QME denied payment (California)

Postby elh919@aol.com on Tue Oct 27, 2009 2:12 pm

I will have to say that for every 5 QME's that are done in our office, 3 of them come back with a denial for payment. About 90% of the denials state that the services are not payable because the treating physician failed to obtain pre-authorization for the services. Once this happens, it takes quite a bit of phone calls to the adjuster, resubmissions of the bills and report so they can look at it again. This can get exasperating since the reports are anywhere from 30 to 70 pages. If the revieweres and or adjusters would read the report in the first place everything is spelled out as to why the report is being generated. I have gone as far as putting a bright piece of paper on top of each bill and report being sent for the first time, with big bold letters stating that this is a Medical-Legal report, I quote the Labor Code that applies, and the Panel Number, and state that the services do not have to be pre-authorized. They still come back with the denial.

Yes, we eventually obtain payment, but what we have to do to finally receive the payment is outrageous. And, yes I agree with John that the only satisfaction is that interest does accrue.

We will still get some old Applicant QME's which are always denied now. Adjusters these days don't know the old rules. I had one adjuster flat out tell me she was not going to pay because it was not pre-authorized. I explained the old way of obtaining QME's (there was even a defense QME report in the file), she acknowledged the Defense QME, but said she does not have to pay for a report that she does not need. Needless to say, penalties are now added and penalies are accruing.

I had one just yesterday that was denied for payment with the reason that it is a denied claim. I left a message for the adjuster, stating it was a Panel QME report, I gave the Panel number, I cited the name of Applicant and Defense Counsel that requested the report, told him that it should be paid per Medical-Legal Fee schedule, yada, yada, yada. I had a message from him this morning stating "if it is a med-legal then please fax me the bill and report and I will put it in line for payment." This should not have to happen, I fax'd him the bill and a 72 page report this morning that should have been in the first place.

I have started a file that keeps track of the report that was denied, the type of report and the reason for the denial, as well as who the carrier is. I now have a carrier that has done this on 4 different occassions. This particular carrier denies for the reason of not obtaining pre-authorization first. I feel that warrants a complaint to the audit unit, citing this particular carrier. So, now it's just a matter of putting all the reports and info together so I can file the complaint.

It's just a game that has to be played regardless of the rules and regulatins that are supposed to be followed. Imagine all the time and effort and lien conferences that could be saved if the adjusters or bill reviewers would read the reports in the first place and realize they are dealing with a Medical Legal report and not a treatment report.

Well, at least I got a chance to vent. Thanks for the thread.
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Re: Panel QME denied payment (California)

Postby appliedpsych on Tue Oct 27, 2009 10:53 pm

I HIGHLY RECOMMEND ALWAYS SENDING THE REPORTS BY TRACKABLE MEANS, AND KEEP ALL COPIES OF PROOF OF DELIVERY.

One problem I see is that some companies do not even route the QME reports to the Claims Examiner, even when they are addressed directly to them.

They either go straight from the mail sorting room to an outside bill review company, to a scanning department, or get routed [incorrectly] to the department that pays for Treatment Services. These all add to the problems. Nine times out of ten, a mishandling of the report by an inexperieinced billing technician or reviewer is the start of the late payment problem.

More than once I have made a courtesy call to the Examiner on day 57 or 58 past service of the QME report, to remind of the upcoming payment window closing, only to have them tell me that they did not even know the report had come in.

There are some companies who do a better job at this than others. The best practice I think would be that all QME reports go directly to the claims examiner, who then can re-route as needed. This would save a lot of late payment penalty and interest for company's.

I make it a practice to make a phone call to the listed adjustor before the QME eval to verify that they are still the active claims examiner. and to make sure that I have all the up to date billing addresses etc. Also I highly suggest NEVER performing a Panel QME until you have a letter from the examiner in your hand verifying that they are aware of and authroizing the appointment, even if it is only a handwritten note on their letterhead. I also always call the CE a few days before the 60 day payment window closes, as a courtesy to let them know that after a certain date the penalty will apply by statute. Several have thanked me for this, as some companies have policies that make late payment penalties a black mark on the record of the CE.

Here are some explanations I have had for late payments. Company names not used so as not to embarrass.

The CE got the report, threw it in the client file, had a blow up with the supervisor, walked off the job, and no one resassigned the case for months.

The CE took vacation to get married, never came back from the honeymoon as she was supposed to, and no one thought to re-assign the files.

The CE went out on an injury to the psyche from a heavy case load, and no one had the key to the file cabinet she left the case files in.

Notes showed that the CE got the report, made case decisions, sent it for bill payment, and no copy of the report or bill was ever seen again until I re-submitted after non-timely payment. No one ever figured out what happened to it, "but it happens pretty regular" according to the CE.

Forty seven pages of a report were apparently scanned wrong side up, leaving 47 blank page imaging files, then the report and bill were shredded and no one knew what the 47 page blank imaging files pertained to.


Luckily, all were resolved with a little respectful communication.
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