Grinberg: The New Med-Authorized Payment Schedule, Half II| Employees Compensation Information

By Gregory Grinberg

Friday, April 9, 2021 | 167 | 0

New obligations are now placed on the parties when they send documents to the medico-legal expert.

§ 9793 (n) required “[a]All documents sent to the doctor to check the documents must be accompanied by an affidavit that the provider of the document has complied with [LC 4062.3] before providing the documents to the doctor. “The declaration must also contain a“ Certificate of the total number of pages of the documents provided ”.

What if there is no such explanation? Then the doctor cannot charge for the review of these records, but the records are also not considered “available” or “received” by the reviewing doctor.

So what’s the big deal? Defendants can easily reduce their bills by not including the attestation so that the medico-legal reviewer either reviews them and is unable to bill them, or does not review them at all and then has no substantial medical evidence report, correct ?

No, dear readers, not even close. It’s a shame that you even suggested such an idea! I know, I know, I suggested it, but we’re all in it together, right? Remember that these new regulations do not in any way limit the obligations of the California Code of Regulations Section 35, which states in subsection (a) that “the Claims Administrator or, if neither is the employer, the evaluator … provides the following information must provide: (1) all records that are created or kept by the treating doctor or doctors treating the employee; (2) Other medical records … that are relevant to the determination of the medical problems in dispute. “

So the defendants must continue to provide the records, and in order to comply with Section 35, they must also include a Section 9793 statement.

Well, with the medico-legal reviewers reading this, I’m sure you would all be interested in hearing about the part where you are finally getting paid more. Well we are finally here.

Section 9795 has been significantly changed and revised. The new multiplier for the Relative Value (RV) system is $ 16.25 versus $ 12.50 (an increase of 30%). There’s even a new missed appointment billing code (ML200) that not only allows the reviewer to bill $ 503.75, but also bills the reviewer for reviewing medical documents over 200 pages at $ 3 per page can.

Missed appointments don’t just mean no-shows, however. This includes cancellation within six working days of the scheduled exam, with the injured employee being more than 30 minutes late, not having access to an interpreter if necessary, or the injured employee leaving before the assessment is complete. The defendants can now receive a credit for the award of an applicant “if fees are incurred for failed appointments and for late cancellations due to the fault or neglect of the injured employee or his representative.”

This will set an interesting pace for those skilled medical assessors who unilaterally set cancellation policies for more than the six business days required by the regulations. When the QME sends notice that cancellations must be in writing at least 10 working days prior to the exam, but the parties cancel seven working days prior to the exam (e.g. if the applicant decides to undergo surgery and approve the usage review ), then the QME could refuse to reset the test until the invoice is paid but would have no legal basis to do so. In such a case, discipline by the medical department may be appropriate.

Evaluations that actually run are billed at a base price of $ 2,015, with the same $ 3 per page over 200 being billable. A re-evaluation within 18 months of the original review will be billed at only $ 1,316.25. The first 200 pages that were reviewed by the evaluator are included, but any records previously sent by the evaluator and already reviewed do not count. In other words, the evaluator cannot charge a review of the records that have already been reviewed and billed.

But what about checking his own reports? What if the panel’s QME spends time reviewing its own 55-page report before reassessing? Will that count for the 200 “new” pages? Case law will show it, as it always does.

Under ML-203, supplemental reports are billed at $ 650. This fee includes reviewing up to 50 pages that have not previously been reviewed by the evaluator. It should be noted that questions that were asked to the evaluator as part of a previous examination and were not answered cannot be the basis for this calculation. So, if a defense attorney asks the QME to clarify whether the injury is specific injury, cumulative trauma, or both (and explain the rationale) and the QME does not answer that question, the follow-up must Letters from the QME are answered without being billed.

Deposition Certificate is now billed at ML204 at $ 455 per hour and still allows a minimum of two hours to be deposited. In contrast, Sub Rosa review is billed at $ 325 per hour. Surprisingly, the defendants are not required to put microwaveable popcorn on the sub-pink DVD, which is clearly an oversight of the authors.

Gregory Grinberg is the managing partner of Gale, Sutow & Associates’ SF Bay South office and a certified employee compensation law specialist. This post was reprinted with permission from Grinberg’s WCDefenseCA blog.