From time to time the DWC feels the need to intervene in not only how the workers’ compensation system is running but also, how people get paid in the workers’ compensation system. What that usually means as defendants, employers and third-party administrators is more work, and sometimes there is no cost savings.

The DWC has done it again, but this time their focus is on the medical-legal fee schedule. I will not go into the past payment schedule for medical-legal evaluations, but some would say the doctors did use it to their advantage. Reason being is that not only could they bill more based on the time spent in evaluating the applicant during the in-person examination, but also in the review of records, either non-medical or medical records that were sent to the doctor for his review in conjunction with his examination.

Typically, a party would send all medical records that were produced in the case, as well as subpoenaed records and possibly non-medical records.  For example, the DWC-1 Claim Form, Application for Adjudication of Claim and possibly other non-medical information, assuming the opposing party did not object. The more documents that were sent to the medical-legal evaluator, the more money they could charge for their report. Not anymore. The reason for the new fee schedule is to limit the potential abuse for the hourly billing schedule and to increase the flat fee payments for medical-legal reporting. One study found a 240% increase in hourly billing from a 2007 Panel QME report. Therefore, the new fee schedule replaced the hourly billing with standard flat fees and the complexity factor of the prior fee schedule has now been eliminated.

New Regulations and Fee Schedule

The new regulations and fee schedule take effect for all medical-legal evaluations and medical-legal deposition testimony starting April 1, 2021. In short, this applies to any AME, QME/PQME initial evaluation, supplemental report or deposition of the doctor as of April 1, 2021. The fee schedule is not complex, but there are some key changes to be aware of.

California Code of Regulations Section 9795 outlines that a comprehensive medical-legal evaluation will cover all evaluations that do not qualify as a follow-up or supplemental, and the doctor can only bill a flat rate of $2,015.00 for the evaluation. However, there can be additional billing by the doctor if he/she reviews over 200 pages. Anything over 200 pages the medical-legal evaluator reviews will be paid at $3.00 per page. Also, if the evaluation is an AME, the fee is increased by 35% and if an interpreter is utilized, there is a 10% increase in the flat fee for either an AME or PQME evaluation.

Additionally, there are increases to the flat fee rate of a comprehensive medical-legal evaluation depending on the specialty of the evaluation. For example, there are specific percentage increases in evaluations for the specialty of psychiatry, psychology, oncology, and toxicology.

A re-evaluation will be paid at the amount of $1,316.25; however, the evaluation must occur within 18 months of the comprehensive evaluation, and it must be an evaluation performed by the same physician. The same 200-page review is included in this flat fee, which would be for new records up to 200 pages sent to the doctor and again the additional $3.00 per page also applies for any pages over 200 the doctor reviews at the time of a re-evaluation.

Two other important services covered by the new fee schedule for an AME/PQME is deposition testimony and supplemental reports. For issuance of a supplemental report, at any time, the doctor can only bill the flat fee of $650.00, which also includes review of 50 pages of new medicals the doctor may receive. If the doctor reviews more than 50 pages at the time of issuing a supplemental report, the same $3.00 per page applies. Payment for deposing the doctor is a little more complex.

The doctor will be paid $455.00 per hour at a minimum, or their usual and customary fee, whichever is less, and rounded to the nearest quarter hour. There will be a minimum of two hours and the physician will be entitled to payment of all itemized, reasonable, and necessary time spent related to the testimony provided (this could include review time or travel time). Also, if the deposition of the doctor is cancelled, the doctor is to be paid a minimum of one hour.

Why Does All This Matter?

Now more than ever, it will be important for the defendant to be sure all issues or concerns are addressed in the cover letter that is sent to the medical-legal evaluator prior to the first comprehensive evaluation. Reason is, if the doctor does not address an issue from the cover letter in his initial report, and a party requests a supplemental report following up on that prior issue, the doctor cannot bill for that supplemental report. Also, the new fee schedule will require a defendant to only send what is necessary and germane to the case to the medical-legal evaluator for review and comment, otherwise anything over 200 pages will be billed at a hefty cost of $3.00 per page. Along with sending records to the medical-legal evaluator, a declaration will need to be provided by the parties. If there is no declaration, the records are not to be reviewed or billed by the doctor and are to be considered not received by the physician.

The new fee schedule will require more judgement and review of the file and records by the defendant in anticipation of a medical-legal evaluation, but also review of opposing counsels’ documents and cover letters to be sure no duplicates are being sent to the medical-legal evaluator.

The new fee schedule was meant to limit the abuse on the part of medical-legal evaluators in their billing practices, but the new fee schedule might have increased costs across the board for all medical-legal evaluations and reports.

Call Our Fresno, CA Workers’ Compensation Defense Attorneys Today

At Yrulegui & Roberts, our California workers’ compensation defense lawyers are skilled, knowledgeable, and effective advocates for clients. If you have questions about the new medical-legal fee schedule, we are here to get you answers. Contact us now for your confidential, no commitment case evaluation. We provide workers’ compensation defense services throughout Central California, including Fresno County, Mariposa County, Merced County, Tulare County, Kings County, San Joaquin County, and Stanislaus County.