An Independent Bill Review (IBR) case affirmed one of the biggest changes to California’s Medical-Legal Fee Schedule (MLFS): an established reimbursement for missed Medical-Legal evaluation appointments.

Previously, the MLFS did not designate a fee for missed appointments.  

Effective April 1, 2021, claims administrators must reimburse physicians for missed appointments at the assigned rate for MLFS billing code ML200. The state confirmed payment is due in a provider’s recent IBR case against PacificComp, regarding a Janitorial Equipment Services employee.

The case serves as a convenient precedent for similar future disputes.

Missed Appointments Under the New MLFS

The new MLFS includes billing code ML200, with a fee of $503.75 for:

• Missed appointments
• The injured worker’s lateness to the appointment in excess of 30 minutes, such that the physician cannot proceed
• Cancellations fewer than 6 days before the scheduled appointment
• Cases in which the injured worker leaves the appointment prematurely

Providers no longer need to establish a separate written agreement to obtain reimbursement for the above circumstances.

Until the recent total overhaul of the MLFS, there was no state-established fee for missed Medical-Legal appointments. The old version of the MLFS included a billing code for missed appointments, ML100. However, the state designated ML100 as “for communication only,” and expressly declared that the code implies no particular amount of compensation.

All that changed on April 1, 2021, when the new MLFS took effect. Unfortunately, some payers haven’t caught up to the new rules — including insurer PacificComp.

Provider Prevails Against PacificComp

PacificComp denied payment for a missed Medical-Legal appointment, downcoding the charge from ML200 to WC012 and claiming that “ACCORDING TO THE OFFICIAL MEDICAL FEE SCHEDULE THE SERVICE HAS A RELATIVE VALUE OF ZERO AND THEREFORE NO PAYMENT IS DUE.”

Had the date of service been prior to April 1 of this year, PacificComp may have been correct. However, as the Explanation of Review (EOR) above shows, the date of service was April 1, meaning the new fee schedule applies.

The provider submitted a Second Review appeal to PacificComp. Given a second chance to reimburse correctly, PacificComp got it wrong again, declaring “THE CHARGE EXCEEDS THE OFFICIAL MEDICAL FEE SCHEDULE ALLOWANCE.”

With no other option, the provider requested IBR.

California’s IBR entity, Maximus, offered PacificComp the usual opportunity to dispute the case’s eligibility. In response, PacificComp issued a third Explanation of Review (EOR) allowing full payment of the disputed charge. However, Pacific Comp did not remit payment.

While agreeing to reimburse correctly is nice, PacificComp’s superfluous EOR was worthless in the absence of actual remuneration. Disregarding PacificComp’s nominally correct but check-less response, Maximus proceeded with IBR and ruled in favor of the provider.

In their Letter of Final Determination, Maximus noted that while PacificComp issued a (largely pointless) third, correct EOR, the insurer failed to include payment — and therefore did not fulfill its obligation to reimburse the provider:

We’re happy to see Maximus establish a clear precedent regarding ML200 for missed Medical-Legal appointments.

That acknowledged, the provider has not received payment (for services rendered or the $180 IBR filing fee the provider paid) from PacificComp as of this writing. Unfortunately, this episode is characteristic of a system in which a claims administrator bogging a provider down in paperwork seems to be an acceptable alternative to simply paying the bill.

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