QME Billing Question (California) (California)

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QME Billing Question (California) (California)

Postby theAxe on Wed Jul 01, 2009 1:36 pm

Reviewing a recent QME report from a usually defense-leaning physician, I noted the physician was billing ML104 rates ($62.50 per 1/4 hour) for typing his own report, which nearly doubled the billable hours.

While I understand the approprateness of billing for physician time used in report preperation, clearly this activity does not require physician expertise, but it sure pays better than having a $10-15 per hour employee type up the report.

Is this being seen by anyone else?

Is this acceptable? Would you authorize payment for this? If not, on what basis would one contest it?
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Re: QME Billing Question (California) (California)

Postby rider001 on Wed Jul 01, 2009 2:40 pm

Thats a pretty good one. Someone has been reading for loop holes.Pay what is reasonable and let them argue in front of the judge how nobody else could have does it like a transcription serivce at 5 cents a line.
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Re: QME Billing Question (California) (California)

Postby jonbrissman on Wed Jul 01, 2009 6:23 pm

Under 8 CCR Sect. 9794, compensation for ML104 includes the physician's time spent "reviewing the records, face-to-face time with the injured worker, preparing the report and, if applicable, any other activities." If the physician chooses to type his own report, that is compensable under report-preparation time. You should pay the physician the amount he billed, and then reassess your use of that physician in future cases.

If you pay only what you think is reasonable and the physician chooses to litigate, you will be ordered to pay the balance plus (likely) a 10% penalty plus (certainly) 7% annual interest plus (maybe) attorney fees and costs for bad-faith actions or tactics. There are possible Audit Unit notifications, costs for representation at WCAB appearances, alienation of a defense-friendly physician . . . Do a risk-versus-reward analysis and you will recognize that you should just pay up on this one.

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Re: QME Billing Question (California) (California)

Postby jakelast@aol.com on Wed Jul 01, 2009 9:09 pm

While i ordinarily respect John's opinion on such issue a great deal, I strongly disagree with the proposition that a physician should be paid for his medical expertise while serving as a transcriptionist. I have seen this type of billing before land objected to the cost of the bill. The WCJ was not impressed with the physicians argument's that he needed to type the report so that he could review it as he typed. The typing added almost 8 hours to the cost of the bill land I might add either the typing portion was seriously inflated or the doc could not type a lick.. )

We paid the physician an ML102 value for his report, which is what it was worth. None of the complexity factors take into account typing one's own report. I will be very surprised if any rational WCJ is willing to pay a doctor for typing his own report at the same rate as preparation of the report. I would even be more suprised if sanctions, penalties etc were imposed.

The language in 9795 regarding ML 104 only allows additional billing for specific activities: "The physician shall be reimbursed at the rate of RV 5, or his or her usual and customary hourly fee, whichever is less, for each quarter hour or portion thereof, rounded to the nearest quarter hour, spent by the physician for any of the following:"

None of the then described activities include typing. ADR 9795 specifically provides that the cost of "typing and transcription services" are included in the ML code costs.
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Re: QME Billing Question (California) (California) (California)

Postby appliedpsych on Thu Jul 02, 2009 12:28 am

I'm a little unclear on the issues being discussed.

Are you trying to say a QME should not bill for the time it takes him to formulate the QME report ? ? !

The basic steps are:
The QME has a face to face interview with the applicant.
Then records are reviewed.
Research is reviewed if needed.

At this point, the QME begins the complex task of analyzing the issues, synthesizing the case information, thinking,
forming, writing, and rewriting the report. At some point, the QME feels the report is finished, successfully addresses
all necessary issues, and cleary answers all referral questions.

Most QME's DO perform all that work themselves. I think that's the law.

Certainly a secretary or typist could not and should not perform that function. Quite illegal.

The Labor Code is clear about this.

4628. (a) Except as provided in subdivision (c), no person, other
than the physician who signs the medical-legal report,
except a nurse
performing those functions routinely performed by a nurse, such as
taking blood pressure, shall examine the injured employee or
participate in the nonclerical preparation of the report
, including
all of the following:
(1) Taking a complete history.
(2) Reviewing and summarizing prior medical records.
(3) Composing and drafting the conclusions of the report.

Please help me understand what you are objecting to.

Attorneys certainly make their living by billing for every minute they even think about a case.

Are you saying that a QME should not be compensated for his or her time thinking about and writing the QME report ?
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Re: QME Billing Question (California) (California)

Postby jakelast@aol.com on Thu Jul 02, 2009 6:54 am

The issue is not the time spent in formulating the report, that is clearly contemplated by the regulations when billing for a ML-104 report.

The question raised was whether the physician was entitled to bill under ML 104 code for the actual typing of the report. The ML 104 code allows a physician to bill the time involved in the factors for extra complexity which would include the research and formulation of the report. The typing and report preparation are included in the clerical functions that are excluded from the language quoted.
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Re: QME Billing Question (California) (California)

Postby steve appell on Thu Jul 02, 2009 7:59 am

LC 4628(d) requires reasonable reimbursement for clerical expense of med legal reports regardless of who actually performs those functions. Therefore, $250 per hour for typing is ridiculous. I would pay the doc $20 per hour for the typing, and dispute the balance.
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Re: QME Billing Question (California) (California)

Postby appliedpsych on Thu Jul 02, 2009 8:14 am

I guess the issue is when does formulation end and typing begin?

In the days of typewriters, a secretary would work from handwritten notes or dictation from the QME to type a smooth report. This process is done by a dwindling number of QME's by dictation or handwriting, over and over again until they get it right. I guess at that point they have a secretary type up the final smooth copy, and I suppose that is the portion you say is not billable.

In my world, and the same is true for many QME's I know, the formulation of the report includes using a word processing program for the acutal writing, editing, re-writing, reviewing, re-thinking, and finally producing a finished product - all done personally by the QME and no one else, within the meaning and intent of formuation, as listed in the regulations.

Most do QME's perform the entire formualtion in a word processing software, and that writing and re-writing, which is the complex formulation process, is certainly way more than typing, and could not be accomplished by anyone but the QME . . . and all that time is certainly billable as the formulation of the report.

The whole production of the report IS the formualtion process, NOT TYPING . . .
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Re: QME Billing Question (California) (California)

Postby jpod on Thu Jul 02, 2009 9:00 am

Let's use an similiar example. The dcotor who billed for transcription must have need for attorney services for managing his/her buisness and personal endevors. Would that person expect to pay his/her attorney the professional hourly fee for typing his correspondence wherein advice of counsel is transmitted?

Outside of WC attorneys fees can be quite a bit more than $350 an hour. Nearly 20 years ago i worked for a international company that engaged in quite a few acquitions as growth strategy. The attorneys the company used to help assist on the acquitions were paid $850 an hour (this was in the early 1990s). I would expect those fees are well into the four figure range now, nearly 20 years later. Would you be willing to pay $1,000 an hour to have that attorney type you a letter?
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Re: QME Billing Question (California) (California)

Postby cmunday on Thu Jul 02, 2009 9:10 am

I read this forum frequently and rarely contribute but I just can't help but respond to this. I can accept that the line between "report preparation" and "typing" or other clerical activity is somewhat blurry but the example provided sounds like some not very busy QME is simply padding his/her billing on the case. The reason I react so strongly to this is that sort of behavior is what has led to things like the predominant cause threshold for psych injuries, SB 899, the demise of voc rehab, etc. That is, when professionals (attorneys and others certainly have abused the system as much as the Drs. have) stretch the law beyond common sense limits then ultimately there's a backlash that hurts everyone including ultimately injured workers. Maybe it's legally correct to argue that "typing" is part of report preparation but I doubt any of us think the law was meant to include such clerical activity as "medical-legal". Hopefully there will be a market place solution to this (that is, word will get around and nobody will use this person). My fear is it becomes known that technically under the law one can bill in such a way and many start to do so and then of course some time down the line we get a backlash. I was peripherally involved in a case where the psychologist charged for 96 hours of record review and report preparation. An attempt to reason with him was met with "hey, that's how long it took me, you have to pay me". That was roughly ten years ago, I never saw another report from this person, and some years back he closed his practice. (Worse yet the report was lousy and "unrateable").

Appliedpsych, if you are in good faith preparing your report using Dragon or other voice recognition software then I think that's reasonable. However, if you were to charge an additional 8 hours to type the report yourself - well, I just don't think that's medical-legal work (and my sense is you would not do such a thing). Further, I really don't think challenging a Dr. for charging for typing will in any way jeopardize your or my legitimate pondering, thinking, writing , and re-writing as billable time for report preparation.


Claude S. Munday, Ph.D.
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