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Industry Insights

Young: A Hearing on the Proposed QME Fee Schedule

  • State: California
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The California Division of Workers' Compensation held a hearing Monday to allow public comment on proposed revisions to the qualified medical evaluator fee schedule.

Julius Young

Julius Young

Approximately 125 participants sat in on the meeting over Zoom, with 17 stakeholders delivering oral statements. The current proposed revisions can be found here.

After several years of stakeholder meetings and fits and starts by the DWC to devise a revised schedule, it is likely that the division will move forward with these proposed revisions, either with or without some additional tweaks.

But it is clear from the comments that there is still a major lack of consensus regarding the best way forward. Multiple commenters noted the possibility of unintended consequences if the proposed regs are enacted. Those commenters included a major employer stakeholder (the California Chamber of Commerce), several QME evaluation groups and the California Applicants' Attorneys Association.

Furthermore, a bunch of individual QMEs warned that the current proposal would not be adequate to encourage their own ongoing service as a QME and would not be sufficient to incentivize new QMEs to come into the California comp system.

On the other hand, there was significant support for the proposed regs from the California Orthopedic Association and from a major QME examination group, ExamWorks. Several supporters noted that it has been a long process and that even if the regs have problems, they can be amended later on, so they appeared to support it as "a step in the right direction.”

Major concerns noted by commenters include the following issues:

  • Changing a follow-up QME from nine months to 18 months.
  • Lack of a strategy to deal with duplicate records.
  • Belief that the proposal may diminish rather than improve report quality.
  • Lack of a cost of living adjustment as recommended by the California State Auditor.
  • Concerns about the per-page of medical records remuneration formula.
  • Lack of strategy to ensure that QMEs are sent records in a timely fashion.
  • Concerns about the attestation required from the party that provides records to the QME.
  • Concerns that the remuneration formula will be very inadequate for complicated cases such as psyche cases and orthopedic injuries to professional athletes.
  • Concerns about whether the provisions for an uncompensated report that did not address the issues will lead to gamesmanship.

Clearly, many commenters believe that if the current QME schedule were tweaked, the result would be more satisfactory than adoption of this proposed schedule.

What’s going on?

Well-intentioned stakeholder meetings failed to reach a consensus on many of these points. Some of the stakeholder “generals” do not speak for all of their troops. Key DWC/Department of Industrial Relations leadership did not attend most of the stakeholder meetings.

Honestly, things have been drifting. QMEs do not trust the DWC and its medical unit personnel. The California State Auditor report added pressure.

It is not a great mix.

I know from various conversations that there are employer stakeholders who have concerns about whether the costs of QME evaluations could explode under this proposal. They are concerned about payments to QMEs based on a flat fee plus a per-page of record review formula, given the large volume of records in some cases.

While I understand the DWC is under pressure to move forward in some way, there may well be unintended consequences that will not be pretty.

I recently spoke with several copy service vendors and it is clear that major advances in records management are available from some of the more sophisticated copy vendors. To the extent that there is concern about duplicate records and having the records available to QMEs in a timely fashion, there are vendors out there who can address these concerns.

Unfortunately, though, the discovery (records retrieval and management) piece of this has not yet been linked to the QME fee schedule discussion. So with the proposed QME fee schedule, there will be an ongoing problem with duplicate records, untimely submission of records, and arguments over report quality and payment for reports.

Perhaps it is too late to bring those issues into the discussion mix now, but maybe not.

In any event, many commenters had valid points, and the DWC would be wise to further tweak their proposal.

Here is the CAAA statement.

Julius Young is an applicants' attorney and a partner for the Boxer & Gerson law firm in Oakland. This column was reprinted with his permission from his Workers Comp Zone blog on the firm's website.

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