NEW MEDICAL LEGAL FEE SCHEDULE
GMK ALERT – Today’s News You Can Use
ISSUE DATE: Wednesday, March 31, 2021
IN THIS ALERT: NEW MEDICAL LEGAL FEE SCHEDULE
New rules governing payment for medical-legal evaluations are taking effect April 1, 2021. These new rules will significantly increase the cost of such evaluations. Because these fees relate to evaluations for the purpose of proving or disproving a contested claim the charges may also be applicable to reports by primary treating physicians as well as QMEs and AMEs.
The new flat fee schedule for “Comprehensive Medical-Legal Evaluations” includes the following payment schedule:
$2,015 for the initial evaluation which fee includes 200 pages for review and $3.00 per page thereafter.
$1,316.25 for a re-evaluation within 18 months of the prior exam which fee includes review of additional 200 pages and $3.00 per page thereafter.
$650 for a supplemental report which fee includes 50 pages of additional records for review and $3.00 per page thereafter.
Fees will not be allowed for information already reviewed or provided in the prior exam.
Fees will not be allowed if the doctor is addressing an issue that was requested in a prior comprehensive medical legal evaluation.
In addition, there are further multipliers that increase the cost of the exams. The basic fee is increased by 10% if an interpreter is used, by 35% for an AME exam and by 45% for an AME exam with an interpreter. If the medical-legal exam is for a psyche QME the charge is doubled and if an interpreter is used the charge is increased by an additional 10%. For a psyche AME exam the charge is increased by 35% and for a psyche AME exam with an interpreter by 45%. If the medical legal exam is for a toxicology or oncology QME exam, the charge is increased by 50% and if an interpreter is used by 60%. For a toxicology or oncology AME exam the charge is increased by 1.85 and for a toxicology or oncology AME exam with an interpreter by 1.95. The toxicology or oncology evaluations must be the primary focus of the medical-legal evaluation. The $3.00 cost per page charge does not increase.
The cost of depositions of the medical-legal examiner is increased to $455 per hour with a 2-hour minimum and if a deposition is cancelled within 8 calendar days of the scheduled deposition, the doctor is allowed 1 hour of deposition time. The fee to review sub rosa video is $325 per hour and the supplemental report must include a verification. If the sub rosa video is received before the issuance of the report related to a medical legal exam, the physician cannot bill for a separate supplemental report. They also cannot bill for review of reports that have been previously reviewed.
Each party sending the records to the medical-legal provider must declare under penalty of perjury the number of records sent and if not, “A physician may not bill for review of documents” that do not include the declaration. However, any documents or records sent to the physician without the required declaration shall not be considered available to the physician for review as part of the medical-legal evaluation.
If there are fees for failed appointments or late cancellations resulting from the “fault or neglect” of the injured worker or representative, the employer can file a petition for credit against the injured worker’s award. The cost for a missed appointment and for an appointment cancelled within 6 business days of the exam is $503.75. The doctor can produce a review of records within 30 days of the missed appointment at $3.00 a page after the first 200 pages and when the face-to-face evaluation or supplemental evaluation takes place, this page count will be excluded from reimbursement.
For letters and records sent to the QME prior to April 1, 2021, the prior fee schedule will apply. However, for exams taking place after April 1, 2021, the new fee schedule will apply.
WHAT THIS MEANS FOR YOU
These new rules will significantly increase the costs of medical-legal evaluations when there are hundreds or often thousands of pages of records that the parties request the physician to review, or the examining physician may later request.
Because these fees are applicable to medical-legal evaluations for the purpose of proving or disproving a contested claim or a disputed medical fact, these fees are likely to apply to charges by primary treating physicians in addition to PQME’s or AMEs, in particular regarding denied claims.
The defendant should seek to meet and confer with the applicant’s attorney on what records and documents are to be sent for review so that there are no duplications in the records being forwarded by each side. Only records relevant to the medical-legal issues should be sent to the examining physician. If the parties cannot agree on what records to send to the examining physician for review, the matter could end up before a Judge to decide, especially when page count is high.
The relevant regulations are contained in 8 CCR §§9793, 9794 and 9795 to which a link can be found below.
https://www.dir.ca.gov/dwc/DWCPropRegs/2020/Medical-Legal-Fee-Schedule/FinalRegulations/MLFS-Corrected-Text-of-Regulations-4-1-21.docx
Please contact Goldman Magdalin & Krikes for guidance that you may need regarding these new rules.