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Claims Adjusters Need Diligence to Avoid Costs Under New MLFS, Defense Attorneys Say

  • State: California
  • Topic: Top
  • - Popular with: Legal
Two months after the Division of Workers’ Compensation adopted an updated Medical-Legal Fee Sc…

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5 Comments (3 Replies)

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Ron Perelman Jun 3, 2021 a 8:02 am PDT

We have not had a raise since 2006. The complexity factors were impossible to deal with. This system is fair. Please screen the records you send us. I know it takes more work, but everyone be happy. BTW, the AME tab could be less, since the 35% increase does not apply to the records, only the report. Before, it was both. PLEASE, get the records to us well in advance, so we can do a good job

M. Hollie Rutkowski Jun 3, 2021 a 8:42 am PDT

The New MLFS came into effect on 4/1/21 and these Def Attys read it two months later. Their advice - tell Claims Administrators to "go over records 'with a fine-tooth comb' to make sure they’re only sending documents that are relevant to their claims." Please read 8 CCR §35(a)(1) on Exchange of Information. (a) The claims administrator shall provide ... the following information to the evaluator: (1) All records prepared or maintained by the employee's treating physician or physicians ... This Reg doesn't give claims administrators much of a choice about cherry picking "relevant" records from all of the Injured Worker's treating physicians.

Kimberley J Pryor Jun 5, 2021 a 2:30 pm PDT

It is the defendant's duty to send records to AME/QME. ( LC 35) Blame them that you do not get them until the day before ( or after) the exam. Labor Code Section 35 (a) The claims administrator, or if none the employer, shall provide, and the injured worker may provide, the following information to the evaluator, whether an AME, Agreed panel QME or QME: (1) All records prepared or maintained by the employee's treating physician or physicians; (2) Other medical records, including any previous treatment records or information, which are relevant to determination of the medical issue(s) in dispute; (3) A letter outlining the medical determination of the primary treating physician or the compensability issue(s) that the evaluator is requested to address in the evaluation, which shall be served on the opposing party no less than 20 days in advance of the evaluation;

Jeffrey Gaines Jun 3, 2021 a 9:06 am PDT

What happens when you have a set of subpoenaed records that is 3000 pages but only 10 pages are relevant. Are you allowed to take the ten pages out of the set of records? Are the applicant's attorney going to force you to send the entire set of records as extortion to settle the case?

Howard J Jun 3, 2021 a 9:23 am PDT

8 CCR §35(a)(1) does not allow the parties to pick and choose what to send from the treating doctor. In addition, I do not trust non-physicians such as claims examiners or attorneys to decide what might or might not be relevant to the claim. The relevance is something for a doctor to determine. If there are medical records to be sent, the offering party will have to indicate the page numbers or the total page count of the records if being offered in entirety. Adjusters and counsel may be wise to rethink potential settlement value in lieu of having to send voluminous records for a doctor to review. Like many changes to our system that I have experienced over the last 40 years, I have concern that costs will go up in many cases.

Randy Bugg Jun 3, 2021 a 1:52 pm PDT

The increased costs will ultimately be felt in the price of goods and services. End story

William Tappin Jun 4, 2021 a 9:09 am PDT

The new regulations will require greater discussion between the parties. It is not going to be acceptable for unilateral redaction of records. However, the parties can agree some records are not relevant. For example, three volumes of Kaiser records that are gyno probably don't need to be sent for a knee evaluation. I have been seeing letters that extract records. This cannot be done. If the parties can't agree , a Judge will intervene. In the case of a psychiatric evaluation almost all records will be relevant. Meet and confer will insulate the parties from the wrath of Judges. Any party being blatantly unreasonable will have issues at Court. Also, please don't play games with page count attestations and penalty of perjury compliance letters. The doctors cannot review records until the compliant cover letter is received. When issues arise request a JOINT delay of the medical exam and go to the Board. Always consider the substantial medical evidence standard when sending records. What is the point of not sending records if the Judge is going to tell you to do say later? Bill Tappin

Kimberley J Pryor Jun 5, 2021 a 2:26 pm PDT

We cannot get carriers to serve what is required by law to be served without a 1/2 dozen hearings on the issue, following months of begging.... The WCJs always say " give them a chance". Now they expect me to MEET and CONFER? Nah... I have a system. Send all the records I think are relevant to the carrier and or defense attorney on disk and tell them to incorporate and attest as to page numbers and send to the QME/AME. if they don't, file for a hearing and ask for sanctions and fees.

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