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Cost problems arise due to the proposed medical-legal fee in California



Employee benefit payers and physicians are concerned about the California Department of Work Compensation's final proposed changes to the medically legal fee schedule released last week, which would significantly reconsider the current compensation system. has been updated since 2006, outlined requirements for compensation to qualified medical evaluators whose task is to evaluate workers' continued right to compensation for workers.

For the past 15 years, QME has been paid an hourly rate – generally from about $ 250 per hour – to review medical records, write medical-legal reports and testify in trials.

Under the proposed amendments, which have been submitted to the California Office of Administrative Law for approval, QMEs will receive fixed fees and an additional $ 3 per page for reviewing records. over 200 pages. Under the proposal, a QME employee to conduct a comprehensive medical-legal evaluation will pay $ 2,01

5 plus the fee per page if applicable. Experts say costs can rise.

"Everyone acknowledged that doctors were underpaid … but this is a completely different system," said Dr. Steven Feinberg, a pain expert and founder of Feinberg Medical Group in Palo Alto, California. "There are some unintended consequences that can be significant."

The biggest issue in litigation is the fee per page because up to about a third of the records typically sent to a QME doctor are duplicates, he said.

Payers have to "either pay significantly more or revise how they do things", says Dr. Jacob Rosenberg, Chief Medical Officer of IPM Medical Group Inc. in Walnut Creek, California and Chairman of the California Society of Industrial Medicine and Surgery. He said payers will often electronically submit thousands of pages of records – many not applicable – for doctors to sift through.

“Large medical providers are very careful and put out many registers. Even for fairly simple (injuries) you will hit 200 pages pretty quickly, says Jeff Adelson, Newport Beach, California-based co-owner of Adelson McLean APC and a longtime employee as a defender. "It's not uncommon for me to see cases with thousands of pages of records. If you send every mail you have, whether relevant or not … you can eat up between $ 15,000 and $ 20,000.

Stacy Jones, senior research assistant at the Oakland-based California Workers Compensation Institute, said payers are very concerned about the side fee result because there is currently "no way to adequately address the duplications because the records come from two different directions. "

If the defense and the seeking attorneys outlined exactly what records each party would send to the QME in advance, it could reduce the likelihood of duplication and an excessive bill, Adelson said.

"Many carriers do not want to pay their lawyer to review medical records … they have tended to just throw everything in an electronic file and send it," said Adelson. "The time to just do a document dump, that part must be "

Dr. Rosenberg said he is hopeful that the fee per page will get payers to decide which items are important." They could pay someone at the end of them $ 30 an hour to sort the items, "he said.

Another issue is the lack of quality control measures in the proposed fee scheme, Jones said.

"In workers' skills, you are stuck with the QME you get – some are very good, many are not good at all," says Dr. Feinberg.

A bad report can result in an inadequate or excessive allocation, but it usually takes longer to resolve the claim, which negatively affects the injured workers, Ms. Jones said.

"(DWC) must really have some kind of quality piece," she said. “One of the steps that the division is starting to take is to set up a committee that will try to review the quality of the reports. There is no benefit to having underqualified or poorly functioning doctors in a system.

DWC did not return the request for comment. If the current proposal is approved by the Office of Administrative Law, it will enter into force on 1 April

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