In general, it appears that after three months of negotiations, the California Division of Workers' Compensation has decided to go its own way and ignore whichever parts of the stakeholder agreement it chooses.

Dr. Robert Weinmann

Medical records received by the qualified medical evaluator are supposed to be studied in time to include mention of them in the QME report. That is hard to do when the records arrive after the patient has been seen. That is why the California Society of Industrial Medicine and Surgery argued during the stakeholders meetings that medical records should be sent to the QMEs 15 days prior to the evaluation.

It should be understood that we're not talking about a few pages: In one case our office received 51 pounds of medical reports. It is almost incomprehensible that DWC rejected the recommendation that reports get submitted 15 days before the patient is seen by the QME.

DWC supports the use of the ML 206 reports, which are defined as "remedial." That means that the original report submitted by the QME was declared insufficient or not responsive to the medical-legal issues raised.

Under this circumstance, a remedial report can be requested. No reimbursement is required for remedial reports which, in fact, are actually traditional supplementals (ML 106 under the present system).  

ML 206 reports are simply unpaid supplementals and can be requested by the carrier without concern for wrongful use of this mechanism. In short, the current DWC does not propose a method to decide if a request for a remedial report is spiteful or just flat out wrong. DWC needs to establish independent dispute panels for instances where the QME disputes the indications for a remedial report.

At the present time, if ML 206 were adopted as is, the requests for remedials would be unilateral and arbitrary.

When Dr. Gabor Vari, CEO of California Medical Evaluators, was asked about ML 206 reports, he stated that the review of the issues was correct and that the provision for ML 206 reports was "too broad and open to abuse by carriers."

Indeed, Vari's assessment was that the ML 206 provisions as currently envisioned by DWC "will increase friction and decrease engagement by QMEs."

Should the number of pages sent to the QME be specified in a cover letter from the sender? CSIMS said yes, DWC said no. This decision leaves it up to the QME to count the pages and state the count under penalty of perjury (a QME office miscount of one page with a 51-pound crate of medicals could lead to an accusation that the QME is guilty of perjury).

Conclusions

DWC does not appear willing to honor the stakeholder agreement to which the QME contingent via CSIMS and DWC appeared to have agreed. Our opinion is that ML 206 and other provisions by the DWC violate the proposed QME fee schedule stakeholder agreement and that the current proposal should be designated as stat DOA (dead on arrival, like right now). 

Dr. Robert Weinmann writes the Politics of Healthcare blog, from which this entry was taken with permission.