If it wasn’t clear before, it certainly is now. Physicians should bill for supplemental Medical-Legal reports requested before April 1, 2021 with billing code ML106, regardless of when the report is actually furnished.

This remains true even though the updated Medical-Legal Fee Schedule (MLFS) — which includes new code ML203 for supplemental reports requested on or after April 1 — is in effect.

Multiple Independent Bill Review (IBR) cases now confirm the facts above. Any physician whose bill is incorrectly denied because of the claims administrator’s error in this regard should appeal, all the way to IBR if necessary. Precedent is on your side.

Supplemental Medical-Legal Report Billing in 2021

The redesigned MLFS took effect on April 1, 2021. However, the state clearly establishes that new billing code ML203, for supplemental reports, applies only to reports requested ON or  AFTER April 1, 2021.

California Code of Regulations Section 9795(f), which lays out the new MLFS, is explicit:

(f) This section shall be effective as of April 1, 2021 and shall apply to the following: (1) Medical-Legal evaluation reports where the examination occurs on or after April 1, 2021; (2) Medical-Legal testimony provided on or after April 1, 2021; and (3) supplemental medical legal reports that are requested on or after April 1, 2021 regardless of the date of the original examination. [Emphasis added]

To bill for supplemental reports requested BEFORE April 1, 2021, the MLFS instructs providers to report ML106.

Are Claims Administrators Trying to Game the MLFS?

In case after case, providers unsuccessfully used Second Review appeals to challenge incorrect denials of ML106. Subsequently, these same providers prevailed at IBR. Why do payers like Liberty Mutual, Sedgwick, and Helmsman keep getting it wrong? Ignorance? General incompetence? Attempts to game the system?

Despite our publishing a step-by-step guide of what not to do — see this post specifically about Liberty Mutual’s screwup — claims administrators continue to lose IBRs, repeatedly, for incorrectly denying payment to a provider who correctly billed ML106.

Below are three Letters of Final Determination from Maximus, the entity employed by California’s Division of Workers’ Compensation (DWC) to conduct IBR. In each case, Maximus overturns the claims administrator’s denial of ML106, asserting that:

"Request for Supplemental Report was received prior to the new medical-legal fee schedule effective April 1, 2021. The time associated with preparing the report and records review were separately identified in the report.”

First, Sedgwick:

Next, Helmsman (A Liberty Mutual ‘relative’):

And finally, Liberty Mutual:

Claims admins, we can’t make it any easier for you, and neither can the state. Currently, DaisyCollect (on our clients’ behalf) has several more pending IBR cases exactly like the ones above — and we have every reason to expect the providers to prevail.

If a party to a workers’ comp dispute requested a supplemental Medical-Legal evaluation report before April 1, the provider should bill ML106.

Get paid in full and on time. With quick & easy tools for authorization, billing, and appeals, DaisyBill helps protect your practice’s revenue. Reach out to learn more.

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