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Posted on: Mar 8, 2021

The Division of Workers’ Compensation released its final proposed update to the Medical Legal Fee Schedule on February 25, and while it attempts to address some issues, it falls short of meeting some of the most important recommendations laid out by the State Auditor’s report in 2019.

CAAA’s Regulations Committee has been an active participant in the rulemaking process since it began, providing recommendations and echoing others from the State Auditor’s report that would hopefully result in adding more QMEs to the system, improving outcomes for injured workers.

In the most recent comments submitted last December, CAAA’s primary concern noted that while this proposal prioritizes increasing payments to physicians for the most basic medical legal evaluations, it leaves adequate compensation for the more complex cases on the cutting room floor.

Most importantly, the unrepresented injured worker is not considered anywhere in this updated fee schedule which now includes significant burdens and requirements on the party seeking an evaluation, which in the vast majority of claims is an unrepresented worker.

For example, an added section includes language stating that any documents sent to a physician for review must include a declaration that the provider has complied with the provisions of Labor Code section 4062.3 before providing the documents and also include a page count of total documents provided. If the declaration isn’t provided, the physician can’t bill for review of the documents, and the records shall not be considered available to the physician or received by the physician for purposes of any regulatory or statutory duty of the physician regarding records and report writing.

An unrepresented injured worker likely won’t know of this burden and likely won’t receive an evaluation since it can’t be billed for by the evaluator.

CAAA also noted that providing adequate compensation is crucial to retaining and recruiting QMEs, yet the DWC has failed to implement a Cost-of-Living Adjustment, even though it was expressly recommended by the State Auditor.

Luckily, there could be a legislative fix. Assembly Bill 404 (Salas, D-Bakersfield) seeks to remedy this issue by implementing a COLA statutorily in hopes of providing medical evaluators with just compensation and avoiding the need to revisit this lengthy regulatory process every couple of years.

Sadly, while all parties will be negatively impacted by the identified inadequacies, injured workers will continue to suffer the most.