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.

If Sedgwick sends an injured worker to a Medical-Legal evaluation with their own medical records, it’s unlikely those records comply with California laws and regulations.

• State law requires that when a party proposes to provide records to a Qualified Medical Evaluator (QME), the information shall be served on the opposing party 20 days before the information is provided to the evaluator.

• All medical records must include a formal declaration and attestation affirming compliance with the California Labor Code and specifying the volume of records sent for review.

Moreover, California regulations permit Sedgwick to deny the record review payment when an evaluator reviews records that lack the required declaration and attestation.

All applicant attorneys should read the Sedgwick letter below, which demonstrates that the nation’s largest workers' comp Third-Party Administrator (TPA) appears to be using injured workers as couriers for medical records and information.

Med-Legal Medical Records: Attestation and Verification

Sedgwick sent the provider, a 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.”

California Labor Code (LAB) Section 4062.3 mandates that parties adhere to a strict protocol when providing medical and nonmedical records to a QME.

Further, California Code of Regulations (CCR) Section 9793 mandates that for a physician to review documents for Medical-Legal purposes, those records must be accompanied by a declaration that the sender adhered to § 4062.3. 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 expect payment 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 exposes the report to challenges that it relies on documents that are “not considered available to” or “received by” the evaluator.

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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