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Why waste money on med-legal bill review?
By Jon C. Brissman, Esq.

Where the only issue is the amount to be paid for medical-legal services, no reason exists why a judge, defense attorney, or claims adjuster cannot review the report and billing and make a dollar-specific payment determination.

Claims adjusters pay substantial sums to bill review services to obtain audits and reimbursement recommendations for medical-legal charges. The reviews are often incorrect. In my practice representing lien claimants, I recently have seen Explanation Of Benefit forms that have denied payment for A.M.E. or Q.M.E. charges on the bases that:

● The claim is denied.
● The provider is not in the employer’s Medical Provider Network.
● Utilization Review did not certify the services.
● The claim is still in litigation.
● The billing was not on a DWC-approved form.
● ML102 is being recharacterized to CPT 99213 to better describe the
services provided.

None of the above is valid for medical-legal charges.

There are six coding levels of medical-legal charges. The Basic Medical-Legal Evaluation (ML102) and Complex Medical-Legal Evaluation (ML103) are flat-rate charges, currently payable at $625.00 and $937.50, respectively. When an interpreter is required and used, the physician’s flat-rate reimbursement is increased by 10%.

The other four categories of Medical-Legal charges are calculated based on the time spent by the physician in a face-to-face meeting with the patient, medical records review, medical research, report preparation, and overhead expenses. The time-based services are a Follow-up Medical-Legal Evaluation (ML101), performed within nine months of a prior medical-legal evaluation; a Comprehensive Medical-legal Evaluation Involving Extraordinary Circumstances (ML104); Medical-Legal testimony (ML105); and a Supplemental Medical-Legal Evaluation (ML106). Note that ML105 and ML106 do not involve an examination of the injured worker.

Currently, physicians are reimbursed $62.50 for each fifteen minutes documented within a time-based medical-legal report, with a one-hour minimum due for a scheduled deposition.

When an Agreed Medical Examiner performs services at any of the code levels, the basic charge is increased by 25%.

Whether a medical-legal report is basic (ML102), Complex (ML103), or Extraordinary Circumstances (ML104) depends on the number of complexity factors involved. Zero, one or two complexity factors means the report is payable at the ML102 rate; the addition of a third factor escalates the rate to the ML103 level; and four or more factors empowers ML104 billing. There are ten complexity factors to be considered:

(1) Two or more hours of face-to-face time by the physician with the injured worker;
(2) Two or more hours of record review by the physician;
(3) Two or more hours of medical research by the physician;
(4) Four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required complexity factor;
(5) Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity factors;
(6) Addressing the issue of medical causation, upon written request of the party or parties requesting the report, or if a bona fide issue of medical causation is discovered in the evaluation;
(7) Addressing the issue of apportionment, when determination of this issue requires the physician to evaluate the claimant's employment by three or more employers, three or more injuries to the same body system or body region as delineated in the Table of Contents of Guides to the Evaluation of Permanent Impairment (Fifth Edition), or two or more or more injuries involving two or more body systems or body regions as delineated in that Table of Contents.
(8) Addressing the issue of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances;
(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.
(10) Addressing the issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section 4610.

Prudent medical-legal providers will state within the body of the report what complexity factors justify a report’s coding. When apportionment is an included factor, the report should specify the qualifying conditions as described in complexity factor number (7) above.

Utilization Review plays no role in determining medical-legal billing issues, and an employer’s MPN arguments are similarly irrelevant. Electronic billing regulations do not apply to medical-legal services.

Where the only issue is the amount to be paid for medical-legal services, no reason exists why a judge, defense attorney, or claims adjuster cannot review the report and billing and make a dollar-specific payment determination. Reserve the expertise of bill review services for medical treatment charges.

Jon C. Brissman is an attorney based in Colton, CA whose practice is exclusively representing lien claimants.

Brissman & Associates
900 E. Washington, Ste. 210
Colton, CA 92324-4192
Voice (909) 512-9205
Fax (909) 512-9209

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