California’s Division of Workers’ Compensation (DWC) will hold a public hearing on significant proposed changes to the regulations governing Medical-Legal evaluations.

The proposals extend the time frame to schedule a Qualified Medical Evaluator (QME) appointment to 90 days (or up to 120 days with the requesting party’s permission), and establish requirements for conducting Medical-Legal evaluations remotely. The DWC calls the changes “necessary to reduce delays and provide greater flexibility for injured workers, physicians and insurance carriers/employers in scheduling medical-legal evaluations.”

The proposed changes seem to underscore the central crisis of California workers’ comp: physicians fleeing the system. Presumably, employers and injured workers alike find it increasingly difficult to set an appointment with a QME — because fewer and fewer physicians are willing to subject their practices to the grueling battle for timely, correct reimbursement.

The hearing will take place on November 15, 2022. The DWC is also accepting written comments.

90 to 120 Day Time Frame to Schedule QME Appointments

Among the proposed changes, summarized in a recent DWC Newsline and outlined in full here, are changes to California Code of Regulations (CCR) Section 31.3. The proposed text of the regulation would read as follows:

(e) If a party with the legal right to schedule an appointment with a QME is unable to obtain an appointment with a selected QME within ninety (90) days of the date of the appointment request, that party may waive the right to a replacement in order to accept an appointment no more than one-hundred-twenty (120) days after the date of the party’s initial request for an appointment. [emphasis added]  

As currently written, CCR § 31.3 initially gives the requesting party 60 days to schedule a Medical-Legal evaluation with the selected QME. Failing that, the party may waive the right to a replacement in order to get an appointment within 90 days of the initial appointment request.

The proposed amendment would allow the party 90 days to schedule the evaluation initially. Failing that, the party may waive their right to a replacement in order to get an appointment within 120 days.

In other words, an injured worker could potentially go four months before even beginning to determine employer liability.

QMEs: Harder and Harder to Find

These proposed changes have what seems to us a very clear subtext: in California, it’s increasingly difficult to find a Medical-Legal evaluator when you need one. Why might that be? From our experience (and the experience of our many physician evaluator clients), possible reasons come to mind:

• Burdensome billing requirements for physician evaluators
• Payer non-compliance that routinely goes unpunished

Even the lack of mandatory e-bill acceptance for Medical-Legal services speaks to the broader issue. Until the administrative expense and hassle of obtaining correct reimbursement for services rendered is reined in, California doctors are likely to prefer less onerous options, such as treating group health or Medicare patients.

Interested parties can attend the hearing on the proposed changes on November 15, 2022 at 12 PM at the following address:

Elihu Harris State Office Building – Auditorium
1515 Clay Street
Oakland, CA  94612

Written comments can be submitted to the Department of Industrial Relations (DIR) via mail, fax, or by email through November 15th as follows:

Maureen Gray, Regulations Coordinator
Department of Industrial Relations
P.O. Box 420603
San Francisco, CA 94142
Fax: (510) 286-0687
Email: dwcrules@dir.ca.gov

Protect your practice revenue. Harness the power of daisyBill software, data, and expertise for faster, better workers’ comp billing.

SCHEDULE A DEMO