A warning for California doctors conducting Medical-Legal evaluations: do not review medical records where the parties failed to deliver those records in accordance with state law and regulations.

Recently, Sedgwick Claims Management Services, Inc. sent a daisyCollect Med-Legal evaluator a letter claiming that the injured worker would bring “any related diagnostic films” to the Medical-Legal evaluation appointment.

This is unacceptable and out of compliance.

State regulations mandate that records come with a formal declaration and attestation affirming compliance with California Labor Code and specifying the volume of records sent for review. If Sedgwick sends an injured worker to a Medical-Legal evaluation with their own medical records in a backpack, it’s unlikely these records comply with the legal requirements.

Moreover, Sedgwick is free to deny payment for reviewing records that were not provided in accordance with the state mandates.

Attention applicant attorneys: As the nation’s largest workers' comp Third-Party Administrator (TPA), Sedgwick seems to be unaware of the legal requirements for delivering medical records (which do not include using injured workers as couriers).

Med-Legal Medical Records: Attestation and Verification

Sedgwick sent the provider, a Qualified Medical Evaluator (QME), the letter below. In it, Sedgwick claimed (emphases ours)

“[Patient] has been asked to bring any related diagnostic films to this appointment. If [patient] fails to provide these films, please perform any necessary tests.”

It’s almost inconceivable that Sedgwick would think this is an appropriate (or legal) way to provide records for a Medical-Legal evaluation.

California Code of Regulations (CCR) Section 9793 mandates that for a physician to review documents for Medical-Legal purposes, those documents must be accompanied by a declaration that the sender has adhered to California Labor Code (LAB) Section 4062.3, which outlines the requirements for providing medical records.

Moreover, the declaration must include an attestation as to the exact number of pages of records the physician must review. CCR § 9793 states (emphases ours):

“Any documents sent to the physician for record review must be accompanied by a declaration under penalty of perjury that the provider of the documents has complied with the provisions of Labor Code section 4062.3…

The declaration must also contain an attestation as to the total page count of the documents provided.

The evaluator cannot use (and certainly cannot bill for) any medical records that fail to meet those standards. If Sedgwick sends an injured worker to a Medical-Legal evaluation with their own medical records, the TPA is effectively setting the evaluator up for payment denial.

§ 9793 states (emphases ours):

A physician may not bill for review of documents that are not provided with this accompanying required declaration…

Any documents or records that are sent to the physician without the required declaration and attestation shall not be considered available to the physician or received by the physician…”

At $3 per page for record review billing code MLPRR, accepting improper medical records risks precluding potentially significant amounts of reimbursement. Moreover, doing so can also imperil the validity of a Medical-Legal report.

Bottom line: Physician evaluators should disregard medical records that do not adhere to LAB § 4062.3 and CCR § 9793, no matter what the payer says.

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