CA Med-Legal Fees, QMEs Under Attack

CA Med-Legal Fees, QMEs Under Attack

A recent study on the current Medical-Legal Fee Schedule (MLFS) has triggered a wave of pearl-clutching by payer advocates. So what has the payer-side pundits groping for the fainting couches? The fact that for the first time in 15 years, physician evaluators are paid more than they were previously — and the increased payment still failed to entice more physicians to become Qualified Medical Evaluators (QMEs).

The California Workers’ Comp Institute (CWCI) — a private group of insurers — cited their proprietary data (unsurprisingly hidden behind a paywall) to demonstrate that Medical-Legal expenses rose by far more than the Division of Workers’ Compensation (DWC) expected. At the same time, the CWCI asserts the new MLFS failed to attract any significant number of new QMEs.

Now, payer advocates are branding the new MLFS a disaster, demonstrating a fine-tuned ability to miss the point.

These payer advocates should ask themselves how insurers and self-insured employers would fare in a world without the relatively few physicians willing to perform QME services — even after being offered higher reimbursements. Instead, these pundits are questioning why physicians are paid so much.  

CWCI: Insurers’ Group Moans About Med-Legal Fees

The current MLFS generally raised reimbursement rates for Medical-Legal services, in several ways. Most significantly, the new MLFS:

  • Created a flat fee for all Comprehensive Medical-Legal Evaluations, replacing the previous formula for calculating reimbursement based on the complexity of the evaluation
  • Created $3 per page record review billing code MLPRR

According to the CWCI — citing its difficult-to-substantiate paywalled data — the two factors above drove Medical-Legal expenses through the roof. The CWCI claims that:

  • Overall costs for Comprehensive Evaluations went up by 53% compared to the previous MLFS, while
  • MLPRR added an average $1,917 to the price of those Comprehensive Evaluations.

But as advocates for QMEs, injured workers, and above all more efficiency in workers’ comp, we must point out that:

  • A single fee for Comprehensive Evaluations is undoubtedly preferable to the hopeless morass of complexity factors that characterized billing under the old, chaotic MLFS.
  • Prior to April 2021, California physician evaluators had not seen a raise since 2006. If expenses jumped more suddenly than payers would prefer, consider it back pay for a decade and a half of plateaued costs, which surely contributed to the current dearth of QMEs.
  • If the cost of MLPRR is a problem, the solution is not to question the record review fee; it’s for attorneys to stop dumping superfluous paperwork on physicians.
  • daisyBill’s (free, publicly available) data shows that from April 1, 2021 to March 31, 2022, daisyBill physician evaluators reviewed 42,421,745 pages of records. Yes, over 42 MILLION pages of records. Does the CWCI expect providers to review these millions of pages of records for free?

Physician evaluators, remember that you hold the power. For now, the CWCI’s dog-whistle data has triggered only whinging* from certain insurer-friendly bloggers. But if this rumbling in the distance starts to sound like the beating of war drums, physicians can very easily assert their value to the system.

If the conversation turns to reducing QME reimbursement, a simple solution is to (briefly) stop conducting Medical-Legal services. If all (or even most) QMEs refused to conduct evaluations for as little as 90 days, insurers and self-insured employers would learn very quickly how critical QME services really are.

Those who advocate for sliding backwards, or changing the law to save payers money in their battles against injured workers, should consider the fact that while Medical-Legal reimbursements are now higher, they’re still — clearly — inadequate to convince physicians to become QMEs. What does that tell you?

From any remotely objective viewpoint, the problem is not that QME pay is too high.

*Word of the Day - Whinging: Like whining, but in a much more irritating and self-pitying way.


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