Discount vendor Reliant tried to slash a California Qualified Medical Evaluator (QME)’s bill by 40% on behalf of Cottingham & Butler Claims Services, LLC (CBCS), the Third-Party Administrator (TPA) for self-insured employer CRST Specialized Transportation, Inc.

Medical-Legal evaluators, remember: you are never under any obligation to accept discounted rates for Medical-Legal services.

Preferred Provider Organizations (PPOs) and discount network vendors have created a lucrative industry by pressuring California providers to accept reduced rates for injured workers’ medical treatment under the Official Medical Fee Schedule (OMFS).

Medical-Legal services are different.

Labor Code Section 5307.11 lets payers establish reimbursement rates outside the OMFS, but it does not apply to Medical-Legal services. Those services fall under the Medical-Legal Fee Schedule (MLFS), a separate fee schedule governed by its own section of the Labor Code, to which § 5307.11 does not apply.

Despite this, payers and vendors routinely approach Medical-Legal evaluators, attempting to get them to accept less than the MLFS reimbursement.

See Reliant’s ludicrous discount “agreement” below, as well as a perfect example of how to respond from a daisyBill QME client.

Reliant Fishes for 40% MLFS Discount (QME Doesn’t Take the Bait)

A daisyBill QME sent a bill to CBCS for a Supplemental Medical-Legal Evaluation. Instead of payment, the QME received the “agreement” below from Reliant, one of many payer-side interlopers that attempt to convince providers to give up their due reimbursement.

Reliant’s offer lists Optum, the bill review vendor for CBCS, as the “Administrator.” However, CBCS, as the employer’s TPA, is responsible for paying this bill and for the actions of any vendors involved.

Like other unsolicited “offers” to surrender revenue, Reliant’s letter tries to gin up a sense of urgency, leading with the all-caps headline **URGENT — CLAIM PENDING** and enjoining the QME to return the signed agreement “TODAY.”

The letter stipulates that the QME will accept $390 for the evaluation, for which the MLFS pays $650: a 40% discount.

In addition to the discount on this specific evaluation, the letter goes further, trying to lock in the discount for future Medical-Legal services. Reliant asks the QME to sign a second time to accept 60% of billed charges on “all eligible claims” in order “To expedite the processing of all future claims.”

Fortunately, our client knew better than to cough up their revenue for no discernible benefit. California regulations establish the legal deadline for paying for Medical-Legal services, regardless of any vendor’s vague promises to “expedite” reimbursement in exchange for 40% off.

As the image above shows, the QME gave the only answer any Medical-Legal evaluator should give in this situation: “NO.”

CA Law Protects Medical-Legal Evaluators From Discount Shenanigans

It’s all too easy for a California provider to sign a discount reimbursement agreement, often under threat of exclusion from Medical Provider Networks, dubious promises of incentives, or other kinds of pressure.

Once the provider signs, particularly in the case of PPOs, the contractual discount is likely to be farmed out to any number of payers, vendors, bill review companies, or other entities (even where state law forbids discount-sharing).

The right to establish discount agreements is rooted in § 5307.11, by which payers may establish reimbursement rates outside those established by Labor Code Section 5307.1, which governs the OMFS (and only the OMFS). Labor Code Section 5307.6 governs the MLFS. These separate statutes are not interchangeable or mutually applicable to both OMFS and MLFS.

If your office receives a discount “agreement” for Medical-Legal services like the one above, take a page from our client. Tell the payer (or its bill review vendor, or its bill review vendor’s vendor, as in this case) to stuff it.

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