And now, the end to a review of the new California Medical-Legal Fee Schedule.

Gregory Grinberg

Last time we covered the different billing codes and appropriate charges at the “base” rate. But nothing in workers’ compensation is immune to circumstance-driven modification, least of all the doctor’s bill.

Those fees discussed earlier were just the base charges. The new regulations also include several modifiers and specialty-specific charges. Agreed medical evaluators now multiply the base by 35%, as opposed to 25% before April 1. The use of an interpreter in an examination adds a 10% increase for the base, while an AME who needed an interpreter gets a 45% bump.

Doctors board certified in toxicology or internal medicine (or certified as qualified medical evaluators in internal medicine) will get a 50% increase to the base for toxicology-focused evaluations, with similar modifiers for interpreters (60%), AMEs (85%) and AMEs using interpreters (95%). The same will apply for oncology exams.

Psychologists and psychiatrists get to charge double the base, 210% if there is an interpreter, 235% if the evaluator is an AME without an interpreter, and 245% for an AME using an interpreter. 

Don’t think the psyche QMEs and AMEs are going to be retiring sooner than before, however. Imagine an orthopedic AME with an interpreter conducting an initial orthopedic examination: That’s a base of $2,015 under ML201, with a 45% increase to $2,921.75.  However, a psyche AME with an interpreter would be getting 245% of the base, or $4,936.75. 

Now look at the difference in time and testing it takes to do an orthopedic exam versus a psyche exam. 

If the orthopedic QME spends three hours face-to-face and another three hours preparing a report and then a few hours reviewing 400 pages, charging $600 for the extra 200 pages, that’s almost $500 per hour. 

By contrast, if a psyche AME spends four hours in a face-to-face interview for the examination, five hours for psychological testing, another six hours preparing a report and reviews the same 400 pages, he or she is getting roughly $330 per hour.

In other words, the new fee schedule might not attract as many psychology and psychiatry medical-legal evaluators into the pool as other specialties.

There is a lot in terms of changes here, and ultimately, the goal is the same as in any situation where more money is put on the table: increase the availability and quality of a particular service. 

Will the increased fees to be paid to medical evaluators attract more physicians to the QME and AME pools? Time will tell.

Perhaps this will just result in the same quality of product with a bigger price tag, or perhaps the defense community will ultimately save money by getting a higher rate of quality, substantive and party-responsive reports that help to actually address the disputes that drive cases to litigation.

Gregory Grinberg is managing partner of Gale, Sutow & Associates’ S.F. Bay South office and a certified specialist in workers’ compensation law. This post is reprinted with permission from Grinberg’s WCDefenseCA blog.