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Michael Post Nov 3, 2016 07:58 AM
Perhaps I can shed some light on to the rising costs of medical legal evaluations. The culprit is the marked increase in the voluminous medical records sent by the defendants (predominantly the defense attorneys) in their attempts to produce evidence to support apportionment. It is not only common to receive hundreds, if not thousands of pages of medical records from various sources, including Kaiser Permanent, but also lengthy (often volumes) of deposition testimony, every lengthy utilization review (and now IMR) report, and also duplicate reports. Added to the request to review these records are CDs/DVDs including additional medical records and surveillance. None of this is provided in any semblance of order and is often duplicative. Reviewing handwritten poorly legible to illegible reports from occupational medicine clinics such as US HealthWorks is time-consuming. Reviewing templated â€œcopy from previousâ€ EHR generated medical reports is time-consuming. What makes matters worse is that records previously reviewed are sent again years later for re-evaluations. Compounding the complexity of these reports are multiple questions from the parties in addition to the standard medical legal questions. The legislative already had increased the complexity of these reports when they altered the legal definition of apportionment and Escobedo, and then complicated matters further with respect to contribution of industrial injuries with Benson. The QME rate of $250 per hour and the AME rate of $312 per hour is a BARGAIN. These rates have not been increased in years and the hourly rate for a ML 102 or ML 103 can be MUCH less than that. Considering forensic charges for civil cases can be double these rates, the carriers should have nothing to complain about. Currently, a treating physician seeing 3 patients per hour, gets reimbursed about $140 per 20 minute appointment, which far exceeds the medical legal rate. If there are any future plans to decrease the reimbursement for these complex medical legal reports, then this best be followed by legislation to simplify the law or the carriers risk getting substandard (useless) reports that do NOT constitute substantial medical evidence. It is already sad enough that large â€œMed Legalâ€ companies that care more about quantity than quality are popping up all over. My advice to the insurance carriers is spend your time and efforts trying to reduce the expenses on UR denials/UR appeals. Come up with your own â€œtreatment formulariesâ€ that bypass UR. If the treatment requested seems sound and makes sense, and it costs less to provide it than to deny it â€“ that will save you money in the long run.
John De Vasure Nov 3, 2016 07:58 AM
Come pay the billing statements for medical legal evaluations and reports. Rare is the one time MMI visit to the PQME.
John Hill Nov 3, 2016 07:58 AM
You hit the nail on the head. reducing reimbursement for med legal reports will yield non-substantiated reports. This will necessitate the need for more depositions and defense attorney billable hours. As it is now, I am frequently bombarded with numerous letters from defense attorneys padding their bills. If the IC wants to find out why med legal cost is increasing, they only have to look at their own attorneys. We all know the IC wants to ULTIMATELY ELIMINATE both applicant and defense attorneys. At that point the IC will have eliminated all cost of a claim.
Michael Post Nov 3, 2016 07:58 AM
If the insurance carriers and their "for profit" and "cost-saving" UR companies would authorize treatment in a prompt fashion, then perhaps the vast majority of injured workers would be MMI when they see the QME/AME. If the legislators would have simplified (instead of complicated) causation of injury and causation of permanent disability (apportionment), then the medical legal reports would be a LOT simpler to complete. If the insurance carriers had to send ONE copy of each report, in chronological order, then reviewing the records would be much less time consuming and costly. Until you have to sit there and sift through volumes of medical records on complex cases, you will have no idea of how tedious it is to provide a quality report that can be used to move cases forward toward some type of resolution. And as an aside, the adoption of the AMA Guides also created issues as the PTPs often do not know how to use them appropriately or refuse to do PR-4s. This conversion to AMA Guides was NOT physician generated. So, in closing, it comes as no surprise that the costs of medical legal evaluations has risen. The system has become more complex, the insurance carriers (and defense attorneys acting on their behalf) are trying to blame permanent disability on anything other than the industrial injury, and drudge up voluminous records to make their (legal) case. Oh - and lets not mention the ridiculous 30 day deadline for getting out these reports for fear of not getting reimbursed or sanctioned by the DWC. When we schedule these medical legals, we never know whether they are ML 102, ML 103, ML 104. It is not uncommon for me to spend nights and weekends getting a complex ML 104 done in a timely fashion. Again, the insurance companies are getting a bargain. Ask the civil attorneys/insurance companies who pay a lot more for expert testimony.