The California Division of Workers’ Compensation agreed to enforce medical-legal billing rules as they are written as part of a settlement with eight doctors who accused the agency of relying on underground regulations to deny their reappointment as qualified medical evaluators.
Although the division didn’t admit to using regulations that weren’t properly vetted by going through the rulemaking process in the Administrative Procedures Act, it still agreed to several changes in how it will interpret the Medical-Legal Fee Schedule in the April 4 agreement.
The division will allow QMEs to cite medical causation as a complexity factor on accepted claims; allow them to bill for medical research within their area of expertise; and it will allow them to charge for time spent preparing reports when using the ML 104 billing code.
Gabor Vari, chief executive officer of California Medical Evaluators, thanked the DWC for pursuing a settlement that would benefit all QMEs in the state.
Vari said the QME system is at something of a “crossroads “ right now, with a recent report from the California Workers’ Compensation Institute finding that the number of QMEs dropped 20%, from 3,239 in 2012 to 2,579 as of September 2017. The division’s enforcement efforts posed a risk not only to the doctors working with California Medical Evaluators, but to other doctors serving as QMEs, Vari said.
“I think that the underground regulations, as they were being implemented, made it very difficult for doctors to justify a decision to continue in the QME system,” he said. “To the extent that the ability for doctors to bill ML 104 is unencumbered by any additional regulations that don’t exist in the letter of the law, I think that will be helpful to stabilize the system.”
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California Medical Evaluators is the only company that was on the frontline of this battle. All other companies looked to California Medical Evaluators lead the way and defend the QME community.
We will continue support QMEs in any current or future challenges they may face with their QME practice. We are here to simplify the process.
