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Jul
21

California’s Med-Legal Mess

In the esoteric world of workers’ comp, California’s “med-legal” issues rank near the top of issues bound to frustrate/infuriate.

Med-legal (analogous to physician review or independent medical exam) may have even moved up a notch or two, as expenses have zoomed after a change in the med-legal fee schedule that went into effect in April of 2021.

The change was intended to:

  • simplify the payment structure by replacing several variations with one flat-fee
  • increase the number of QMEs – Qualified Medical Examiners
  • and increase the number of oncologists and toxicologists,
  • reduce overuse of “supplemental” reports
  • do this all without more than a 25% increase in aggregate med-legal fees.

CWCI’s research indicated that results appear to be far less than intended…

  • the number of QMEs increased slightly – up 134 – with most ortho surgeons – NOT oncologists and toxicologists
  • there was no decrease in supplemental report services (e.g. billing for more pages reviewed)
  • and the average paid per month for comprehensive evaluations went up more than 50%.

Thanks to CWCI for sharing the details…need more details?

Sign up for CWCI’s webinar on Wednesday, July 27 at 10 a.m. (Pacific). Senior Research Associate Stacy Jones, who authored the study, and CWCI General Counsel Sara Widener-Brightwell, will review those changes and discuss the results of the study.  The program will be followed by a live Q&A session.

What does this mean for you?

As if we needed it, another entry in the Hall of Unintended Consequences tells us – YET AGAIN – regs have to be carefully thought through, responses anticipated and planned for, profiteer strategies gamed out, and then – AND ONLY THEN – finalized.


4 thoughts on “California’s Med-Legal Mess”

  1. As a QME since the inception of the system in 1992 I have seen my fair share of the ups and downs of this process. In my office we have carefully analyzed the impact of the 04/01/2022 fee schedule on our billing and revenue. I should point out that I perform an average of 15+ QME evals per month, and write an average of 20 supplemental reports each month as well. Our experience on QME case average revenue is that our average value per case has declined by 15% in the past 15 months not increased as the CWCI would suggest. As a board member of the California Society of Industrial Injury and Surgery, I hear from many of my QME peers in various specialties that they are finding their statistics post new fee schedule are quite similar to mine. This raises questions as to the validity of the data CWCI is relying upon or the algorithm they are applying. One can not ignore that the data used comes from the stake holder in this system who has the most to gain by making changes in the fee system in order to reduce their costs. I believe that if the real facts are of interest, then perhaps an independent assessment of the issue should be considered.

    1. Hello Richard and thanks for joining the conversation.

      I’m surprised indeed that a medical professional such as yourself would question the validity of actual data based solely on your own experience and what you’ve “heard” from others. Medicine is, after all, evidence-based, or at least it should be.

      Conclusions based on anecdote often differ from those based on actual data. I would suggest you would be well served to participate in CWCI’s webinar and ask whatever questions you deem appropriate in the Q&A session.

      Finally, your inference that somehow the people at CWCI have twisted their analysis to suit the industry is insulting, unprofessional and not supported by anything other than your own opinion. Your attack is as inappropriate and unprofessional as those by others who cast aspersions on the field of chiropractic based solely on rumor and innuendo.

      be well – Joe

  2. Mr. Paduda – your statement “As if we needed it, another entry in the Hall of Unintended Consequences tells us – YET AGAIN – regs have to be carefully thought through, responses anticipated and planned for, profiteer strategies gamed out, and then – AND ONLY THEN – finalized” is quite trite. Of course they do – you’re completely correct. And, that is what we – the members of the New Medical Legal Fee Schedule Committed did. We carefully thought out our proposal on the new fee schedule. As a group of approximately 40 of the top minds in the industry, we came together to mastermind and project forward the eventualities that we could conceive. We addressed every concern of every party and player. We put forth what we imagined as an equitable system. We could not anticipate EVERY possible consideration at the time and neither you, nor anyone else could. And, unless I am mistaken, where you there? Were YOU involved in the development of the New Medical Legal Fee Schedule? I don’t recall meeting you. So, for the hardworking group of dedicated professionals here in the State of California all working tirelessly to improve the system, we ask that you join the “positive train” and ask yourself what can YOU do to help improve the system. In the alternative, if you don’t have anything positive to say…..well…you know the rest.

    1. Hello Perry – and welcome to Managed Care Matters.

      Allow me to respond.

      Of course it is always easier to see what happens after regulations are put in place; I’ve been involved in many such efforts on issues ranging from physician dispensing to opioid management, from network access to utilization review. I was not involved in the discussions regarding the changes discussed in this post – my involvement is irrelevant to this discussion.

      You assert that you and “approximately 40 of the top minds in the industry” “masterminded” and “projected forward” the eventualities that could occur.

      Well, you failed.

      Moreover, I’d suggest that instead of attacking me, it would behoove you to reflect on what went wrong and why. I always acknowledge my mistakes publicly; you can read those acknowledgements elsewhere on this blog. I’ve found it is always productive to do so; hopefully you will as well.

      It is not up to me to fix what is obviously a broken system. That is up to the stakeholders; as it is clear the goals have not been met, I would suggest you and your colleagues should “continue working tirelessly to improve the system”.

      Be well – Joe

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Joe Paduda is the principal of Health Strategy Associates

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A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.

 

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