CA Med-Legal: Q&A for Confused Physicians

CA Med-Legal: Q&A for Confused Physicians

Recently, a physician evaluator reached out to us with questions regarding Medical-Legal services for California workers’ comp. Rather than share the answers with this physician alone, here we offer our responses for the benefit of all California Qualified Medical Evaluators (QMEs) and Agreed Medical Evaluators (AMEs).

Read on for important information on how to bill for examinations and reports outside the Medical-Legal Fee Schedule (MLFS), as well as for psychiatric/psychological Medical-Legal evaluations.  

Question: Evaluations Outside the MLFS

Physician Question: I've been investigating the significant cuts (PPO & Non-PPO) in OMFS billings for non-AME/QME flat rate examinations and reports. The cuts I've seen total approximately 40% of allowed OMFS. What recourse does the physician have?

Answer: In some cases, a qualified physician who is not acting as the AME or panel-selected QME may be asked to conduct examinations or issue reports in the interest of resolving a dispute. Such services are billed outside the MLFS.

California’s Official Medical Fee Schedule (OMFS) does not include any specific billing codes or rates for non-AME/QME examinations and reports. To receive payment for these services, the physician should enter into a separate reimbursement contract under California Labor Code Section 5307.11, which allows providers and payers to agree to reimbursement rates outside of any state fee schedule.

Crucially, the physician should stipulate in the reimbursement contract that Preferred Provider Organization (PPO) and other discounts do not apply to contracted services. This way, a physician can set a reasonable price for the requested services, and bill without fear of any discount-network shenanigans.

Bonus for providers: we offer two free templates for reimbursement contracts under Labor Code §5307.11 — one for reports, and one for examinations.

It is worth noting that MLFS rates are never subject to PPO or other network discounts (Seriously — never. Just ask Sedgwick).

Psychiatric/Psychological Medical-Legal Evaluations

Physician Question: I am also an AME/QME, but can't envision a flat fee structure working for complex Neuropsychology and Psychological evaluations. The flat fee schedule encourages doing short robo-type reports accompanied by a lot of unnecessary testing and only taking cases with high-page-count medical files. What are your thoughts?

Answer: Here we have to disagree with the premise of the question. In our opinion, the revamped MLFS adequately reimburses for psychiatric/psychological Medical-Legal evaluations.

The new MLFS streamlined billing by replacing the more convoluted complexity and time-based factors previously used to determine reimbursement with flat fees. This made it much easier to obtain appropriate reimbursement for Medical-Legal services, including psychological examinations and reports.

In fact, the MLFS reimburses psychiatrists and psychologists at twice the standard rate or more, when the evaluation is primarily psychiatric or psychological. The physician must simply use MLFS modifier -96 as follows:

1. Apply modifier -96 to the billing code (ML201, ML202, or ML203 only) when the evaluation is performed by a psychiatrist/psychologist and a psychiatric or psychological evaluation is the primary focus of the Medical-Legal evaluation.

2. Multiply the standard reimbursement by 2.

3. Where applicable, for ML201 or ML202:

  • When modifier -93 for interpreter services is also applicable, multiply standard reimbursement by 2.1
  • When modifier -94 for AME services is also applicable, multiply standard reimbursement by 2.35
  • When modifiers -93 and -94 are also applicable, multiply standard reimbursement by 2.45

Per the MLFS, reimbursements for psychiatric/psychological Medical-Legal evaluations are as follows:

ML201

ML202

ML203

Standard MLFS Reimbursement

$2,015

$1,316.25

$650

Reimbursement, Modifier -96

$4,030

$2,632.50

$1,300

Reimbursement, Modifiers -96 + -93

$4,231,50

$2,764.13

n/a

Reimbursement, Modifiers -96 + -94

$4,735.25

$3,093.19

n/a

Reimbursement, Modifiers -96 + -93 + -94

$4,936.75

$3,224.81

n/a

Of course, as the physician correctly points out, huge volumes of medical records to review are one of the biggest drivers of Medical-Legal expenditures, a situation which drastically (and misleadingly) skews the data on workers’ comp costs overall. This, however, is a problem best addressed between the parties and their attorneys.


Med-Legal billing requires specialized expertise. daisyCollect professionals use our advanced software (and years of experience) to protect your practice. Request a demo below:

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DaisyBill provides content as an insightful service to its readers and clients. It does not offer legal advice and cannot guarantee the accuracy or suitability of its content for a particular purpose.

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