Fee for Medical-Legal Report

[frazzled]

As I've discussed on previous threads, I am getting ready to fight a medical-legal decision.

I am wondering if anyone can tell me how much my treating doctor would be paid to write a rebuttal report (assuming he wants do it, of course).

Possibly not the actual amount, but how he would bill it and to whom. I would like have the information at hand when I ask him. I feel it would be awkward if he had to put a lien on my claim, because I have no idea when I will settle; and that sounds kind of iffy anyway.

Maybe the docs have that information already?

Any info appreciated...

[Charles Stevens]

Frazzled, I think you should call the WCAB, and talk to an Information & Assistance Officer, and ASK FOR A SUPERVISOR, and get the NAME of the Supervisor who is GIVING you the Codes, etc....CYA!!!!!

The I&A Supervisor should be able to give you the EXACT Labor Codes that apply, As WELL as the Billing CODE numbers that apply, and the ranges of allowable charges for the preparation of the report and DOCUMENT REVIEW.

Unfortunately, I do not have the information at my immediate disposal; perhaps BvIA does.

But, you want to be ACCURATE when you provide the information to your Doctor, just to be sure that the IC/CA/DA can't OBJECT or REFUSE to pay!!!

Good Luck, and as always, keep us posted!

[BvIA]

This is based on legislation from 1989/1993, and no doubt there have been changes..http://www.dir.ca.gov/chswc/med%5Fle....html#Heading4,

Med/legal evaluations are not a simple as asking your PTP to review and comment, issue a report...and have that constitute a Medical/Legal evaluation. I know we keep going around on this...
Under the new system/rules a Med/Legal evaluation is performed by a PQME for an unrepped IW... an AME for a repped IW...but while a repped IW out of state can use any doctor who agrees to perform the evaluation, per the rules established by the DWC Medical Unit, and Panel QME must be under contract/agreement with the DWC Medical Unit...an unrepped IW cannot enter into an 'agreement' with the ER/IC for an AME evaluation.

A 'record review' and subsequent report does not constitute a 'medical/legal evaluation'...While the L.C. provides that either party may request a PQME/AME med/legal report, there are still rules that govern this... the CA isn't going to just pay a bill for this report because you dispute a AME report/opinion...nor would they be liable for this.


Here are some comments/rule making on ML fees...http://www.dir.ca.gov/dwc/DWCPropReg...mmentChart.pdf

ML fees are also contingent upon the specialty of the evaluator performing the service...
Medical/Legal evaluations performed by a PQME are done in Calif...and are based/requested due to a disputed medical issue...that is why the CA provides a check for reasonable mileage/acommodation to the IW prior to the appt. There are numerous instances on this and other boards discussing an IW having to return to Calif for a PQME/AME evaluation.

I am wondering if anyone can tell me how much my treating doctor would be paid to write a rebuttal report

Your doctor/PTP is out of state, he is not subject to the OMFS of Calif DWC. He is free to bill he 'usual and customary' fees. The billing would go to the CA/IC...

As I've discussed on previous threads, I am getting ready to fight a medical-legal decision.

I don't recall all the details of your dispute..but the way your challenge a AME evaluation/opinion/report is through a deposition by your AA...s/he can have the PTP report to refute the issues in hand... OR a supplemental report, detailing the disputed issues, and providing the medical evidence/information that may not have been available at the intitial evaluation.
Or, though a hearing with substantial EBM reporting by your PTP...

After all, the parties ''agreed'' to use the AME... and to abide by the subsequest opinion/report.
What you are attempting is not unusual...one side or the other is always dissatisfied with the AME reports...this time, the IC was obviously happy with the outcome..and you aren't...
I know Charles said the PTP is free to charge the OMFS...and he is...
I would not expect that your PTP will be compensated for the report you are requesting him to produce...not at the med/legal fee schedule anyway.
I would see your PTP having to file a lien here.. and eventually hiring a lien representative to appear at the WCAB to protect his interests.
You are attempting to fight Calif statutes from a long distance position...

[Charles Stevens]

BvIA, I must respectfully point out that Frazzled is NOT ASKING her PTP to prepare ANYTHING on the level of a "Med-Legal EVALUATION".

She has an AME, and HE performs the Med-legal EVALUATIONS and reports on the FINDINGS during the EVALUATION, and no one ELSE....

Frazzled is NOT REQUESTING her PTP to perform a "Med-legal EVALUATION", but rather, she is asking her PTP to RESPOND in WRITING to the AME's report, by issuing a Rebuttal REPORT, for which, the PTP is allowed to BILL as a MED-LEGAL REPORT.....

A Med-legal EVALUATION and a Med-legal REPORT are "Two different ANIMALS" under the LC/and billing codes.....IMVHO....

[frazzled]

Thanks, guys, for the info!

I will follow up on it all, try to sort this out, and let everyone know what happens. I also have thought about which docs in CA I would ask; there are two that I trust; and they are in the IC's network.

That would make things easier, I'm sure, since they're in-state. But I'll see what happens here first.

[Charles Stevens]

ADDENDUM: Since Frazzled is STUCK with this AME, UNTIL and UNLESS she IS able to ditch the AME, and therefore, be ENTITLED to a PQME, as a "NOW UNREPPED IW", she MUST have her PTP render a rebuttal report.....

Frazzled's NEXT step is to confront the IC/CA with the "legal argument/LC Codes" that SUPPORTs her assertion that since she is NOW unrepped, and as such, is NOT REQUIRED to CONTINUE WITH THIS AME, she is demanding that it is her RIGHT to dump the AME, and choose a PANEL QME.....

Depending on the CA's response, Frazzled may very well have to take this matter to a HEARING, and let a JUDGE decide. As you are aware BvIA, SOME Judge's WILL ALLOW the unrepped IW to dump the AME, and get a PQME, and others WILL NOT.

It just DEPENDS on the PARTICULAR JUDGE who is the arbiter in her case....and IF the Judge DOES allow her to go the PQME and escape the clutches of her crappy AME, the IC/DA MIGHT RECON the Judge's decision!

Until such time this issue is RESOLVED, Frazzled NEEDS to have her PTP/Specialist CONTINUE to REFUTE the AME's report/opinions....

[BvIA]

There shouldn't be a problem with getting a new panel list for a PQME to settle a disputed medical issue... the L C is pretty clear that the ER/IC shall not attempt to ''agree'' on an AME with an unrepped IW... the problem we've always seen is the language in 4062.2/4062.3 in the last paragraph...

All frazzled needs here is a basic report from the PTP addressing the issues at question in the AME report...
Shouldn't be need for 'record review' etc if the PTP is familiar with the statuts/medical reporting of the claim...
Shouldn't be need for all the discussion about whether or not a 'med/legal' fee schedule is necessary to present to the PTP for the refuting report/opinion.

As I said, the doctor is out of state, and is not subject to the Calif OMFS...standard reporting or otherwise...

From what I've read, as a rule, in the interest of expediation and ''fairness'' to the IW... and the codes allow for the judges to ''swing toward the IW''... most WCAB judges/boards will provide for a IW to secure a PQME once unrepped.
For some reason, the WCAB allows for ''legislation from the bench'' in WC in Calif...Martha would probably call that a ''good thing''...

NOT REQUIRED to CONTINUE WITH THIS AME, she is demanding that it is her RIGHT to dump the AME, and choose a PANEL QME.....

This may very well be the case... the only problem may be ..just because you don't like the opinion/reporting of the AME... is not just cause for a PQME to resolve the same disputed medical issue...(?)
This whole thing is revolving around that... frazzled doesn't like the AME's opinion...I'm not taking the IC's side here...just pointing out that ''doctor shopping'' is frowned upon...and that is what appears to be the case here...(if you look at this from the side of a CA, and possibly a WCAB judge....)

[Charles Stevens]

If Frazzled's AME is OPINING OUT OF HIS AREA OF EXPERTISE, then that might be considered good grounds to request the PQME panel.

But, since the LC MIGHT allow an IW who is now unrepped and who has an AME, but does not AGREE to HAVE an AME anymore, and therefore, wishes to EXERCISE that right to request a PQME, then I don't think the IW has to "elaborate" any further.....just my humble opinion.

[BvIA]

The labor code addresses this for us...

4067. If the jurisdiction of the appeals board is invoked pursuant
to Section 5803 upon the grounds that the effects of the injury have
recurred, increased, diminished, or terminated, a formal medical
evaluation shall be obtained pursuant to this article.
When an agreed medical evaluator or a qualified medical evaluator
selected by an unrepresented employee from a three-member panel has
previously made a formal medical evaluation of the same or similar
issues, the subsequent or additional formal medical evaluation shall
be conducted by the same agreed medical evaluator or qualified
medical evaluator, unless
1) the workers' compensation judge has made a
finding that he or she did not rely on the prior evaluator's formal
medical evaluation,

2) any party contested the original medical
evaluation by filing an application for adjudication,

3)the unrepresented employee hired an attorney and selected a qualified
medical evaluator to conduct another evaluation pursuant to
subdivision (b) of Section 4064,

4) or the prior evaluator is no longer
qualified or readily available to prepare a formal medical
evaluation,

in which case Sections 4061 or 4062, as the case may be,
shall apply as if there had been no prior formal medical evaluation.

(I have rearranged the above for clarity...)

So frazzled, as you are unrepped at this time, it appears you will have to file a DOR for hearing to 'dispute' the AME reporting...which means too that you'll be making a trip to California...

I am wondering if anyone can tell me how much my treating doctor would be paid to write a rebuttal report (assuming he wants do it, of course).

Possibly not the actual amount, but how he would bill it and to whom.

You can go to section 4620 in the labor code for a defination of a M/L evaluation/report.
If the PTP isn't performing any of these functions, he wouldn't bill at the ML fee schedule.
There may be billing info in the OMFS he'd like, but again, being out of state he is not bound by Calif laws/fee schedules...