On Thursday April 1, 2021, the Office of Administrative Law approved the new medical-legal fee schedule proposed by the California Division of Workers’ Compensation (DWC). The new fee schedule was created in an effort to reduce billing disputes, lower frictional costs, increase the quality of the medical-legal reports and entice more physicians to join the QME panel system. We anticipate these changes will increase litigation costs and may cause substantial medical-legal fees if safeguards are not implemented.

The new fee schedule applies to all medical-legal evaluations on or after 4/1/21 as well as supplemental reports requested after 4/1/21.  It will also apply to medical-legal reports billed by primary treating physicians.

The new medical-legal fees are outlined below:

Missed Appointments

  • Fee: $503.75
  • Code: ML200

Applies when:

  • Interpreter does not appear for evaluation.
  • Injured worker leaves before completion of the evaluation.
  • Cancellation within 6 business days of the scheduled appointment.

Comprehensive Medical-Legal Evaluations

  • Fee: $2,015.00
  • Code: ML201
  • Applies to the initial evaluation or the first evaluation in an 18-month period.
  • The evaluation includes review of up to 200 pages of records.
  • It must involve an examination of the employee.
  • Review of records in excess of 200 pages is reimbursed at a rate of $3.00 per page.

Follow-up Medical-Legal Evaluations

  • Fee: $1,316.25
  • Code: ML202
  • Applies to any subsequent comprehensive evaluation within 18 months of the initial evaluation.
  • This fee includes review of up to 200 pages of records that were not reviewed as part of the initial evaluation.
  • Review of records in excess of 200 pages (records not reviewed at initial evaluation) reimbursed at a rate of $3.00 per page.

Supplemental Medical-Legal Evaluations

  • Fee: $650.00
  • Code: M203
  • Does not involve an examination of the patient.
  • Results in preparation of a narrative medical report.
  • Review of records in excess of 50 pages reimbursed at a rate of $3.00 per page.
  • Fees for a supplemental report are not allowed if:
    • Records reviewed were provided to the physician for review before the initial or follow-up evaluations.
    • Supplemental report addresses an issue the parties asked the physician to address in a prior med-legal evaluation.

Medical-Legal Testimony

  • Fee: $455.00 per hour (or physician’s usual and customary fee, if lower)
  • Code: ML204
  • Physician is entitled to bill a minimum of 2 hours for deposition.
  • If the deposition is canceled within fewer than 8 calendar days prior notice, physician is entitled to bill 1 hour of time.

Medical-Legal Review of Sub Rosa Evidence

  • Fee: $325.00 per hour (or physician’s usual and customary fee, if lower)
  • Code: ML205
  • No minimum time allotment.
  • Physician must capture time spent reviewing evidence to the nearest quarter-hour, verified under penalty of perjury.
  • The fee does not include production of a medical-legal report. The fee for time spent reviewing the recording will be included in the billing for the initial, follow-up or supplemental medical- report.

Additional Fee Modifiers

  • Interpreter
    • Fees for evaluation requiring an interpreter are increased by 10%.
  • Agreed Medical Evaluator
    • Fees for evaluations performed by an AME are increased by 35%.
  • Psychiatrists and Psychologists
    • When psychiatric/psychological evaluation is the primary focus of the exam, fees for evaluation are doubled (100%).
  • Toxicologists and Oncologists
    • When toxicology or oncology is the primary focus of the exam and the physician is an internal medicine specialist, fees are increased by 50%.

Court-Ordered Evaluations

  • When a medical-legal evaluation is ordered by a Workers’ Compensation Judge, the Judge has authority and discretion to apply the appropriate modifier to that evaluation.

 

New Requirement of Verifications and Declarations

  • The physician on all medical-legal evaluations must include a declaration under penalty of perjury giving the total number of pages of records reviewed in connection with the evaluation and report.
  • The parties must also issue declarations under penalty of perjury that they have complied with Labor Code 4062.3 prior to providing the records to the physician.
  • The declaration must include an attestation of the total page count of the documents provided for review.
  • A physician may not bill for review of documents provided without the declaration.

The increased costs for review of records will have a significant impact on settlement strategies, litigation costs and claim reserves. As claim files often contain thousands of pages of medical records, it will be critical for both examiners and defense attorneys to review which records are necessary to send to the physician in order to minimize the costs of the exam. In some cases, consideration of resolving the case without a medical-legal evaluation may be the best strategy.

It will be important to review all cost factors in developing a strategy for each claim. We recommend the following be considered in those efforts:

  • Develop a cost benefit analysis to determine if it is financially prudent to proceed with a medical-legal evaluation.
  • Critically review records and prepare to send only those that are necessary to address the issues on the claim.
  • Work with opposing parties to agree on the records that will be provided.
  • Secure litigation budgets from defense attorneys on costs associated with paring down records.
  • If there is a disagreement on what records are relevant, file for an expedited hearing.
  • Evaluate whether an early settlement is more cost effective than proceeding with a medical-legal evaluation, particularly when multiple medical-legal evaluations are required.

Athens will continue to evaluate the impact of the new medical-legal fee schedule and will ensure we are taking the necessary steps to control costs associated with the medical legal process.