Payments for medical-legal services used to resolve medical disputes over compensation claims in California’s work injury claims have increased “sharply” under the new medical legal fee scheme that went into effect in 2021, according to a CWCI study.
In April 2021, anticipating a 25% cost increase, the California Division of Workers’ Compensation implemented a new fee schedule for the first time since 2006. The previous schedule provided fixed fees for “basic” and “complex” comprehensive evaluations and time-based payments for evaluations. involving “extraordinary circumstances.”
The new schedule, which CWCI researchers found cost-raising previous predictions, replaced those three service levels with a single fixed fee of $ 2,025 for forensic pathologists, plus $ 3 per page for reviews exceeding 200 pages and time-based payments for video reviews. The new schedule also continued to allow additional fees for evaluations of those who involved an interpreter and increased fees multipliers to certain medical specialists.
By comparing the use and reimbursement of medical legal services performed before and after the effective date of the new scheme, using data from claims during the accident years 2015 to 2021, CWCI found that reimbursement of the three levels of evaluations with a single comprehensive evaluation is reimbursed to a fixed fee “Probably had the biggest impact on average payments.”
Basic evaluations accounted for about 40% of the evaluations paid under the new comprehensive service code and the new fixed fee increased the payment for these services by 222%. More complex evaluations accounted for 18% of the new evaluations and payments for these services increased by 115%.
While regulators hoped the new schedule would lead to a redistribution of medical legal services, with fewer supplementary reports, reports increased from 34.2% of medical legal services in 2019 to 37.8% below the new schedule.