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Monday, October 15, 2018

Payment to PTP for Med-Legal Work Depends on Facts

  • By Greg Jones
  • State: California
  • Topic: Top
  • - Popular with: Legal
  • -  13 shares
California’s Labor Code and Medical-Legal Fee Schedule both appear to allow a primary treating…

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7 Comments (5 Replies)

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John Don Oct 15, 2018 a 3:10 pm PDT

God forbid we let the doctor most familiar with the facts say anything to help the injured worker.....

Christopher Lear Oct 15, 2018 a 7:10 pm PDT

This assumes: 1) The worker is injured; 2) The worker is industrially injured; 3) The doctor is the person most familiar with the facts; 4) The doctor is motivated solely by a desire to report accurately and not motivated by a desire for monetary compensation. And why would the doctor need to say anything "to help the injured worker", rather than reporting honestly and accurately, even if it does not help the injured worker. Unless you admit that a doctor reporting adverse to the injured workers' claim of industrial injury or reducing the amount of treatment or impairment levels is actually helping the injured worker.

Stephanie Thomas Oct 16, 2018 a 2:10 am PDT

A loaded statement. Think on this. Two patients with the same name, same employer, insurance carrier, who uses the same set of doctors (1), and those doctors use the same set of labs for blood work, same pharmacy, same x-ray provider, same historians and same new people in the offices, and same copier service. What is the percentage of ERROR? Who else would be appropriate for input, WHEN YOU LEAVE THE PATIENT OUT OF THE BILLING PROCESS, WHO COULD VERIFY THAT THE DOCTOR DID ALL THAT WAS ON THE BILL. The only person that could verify the patient in the Med-Legal, is the patient and the doctor. So when I saw for comment, in the case above, leads to file negligence, and patient applied medical treatment. And in the case above, the bate numbers and file numbers on multiple sheets on different dates show the patient is not who the file say they are. The other outside entities that you mentioned above, has NO RELATIONSHIP WITH THE PATIENT. They work the file, and sign under penalty of perjury, present it to the Judge, who signs off on the file. The file then is reviewed by the Auditor, auditor catches the error,

Stephanie Thomas Oct 16, 2018 a 2:10 am PDT

A loaded statement. Think on this. Two patients with the same name, same employer, insurance carrier, who uses the same set of doctors (1), and those doctors use the same set of labs for blood work, same pharmacy, same x-ray provider, same historians and same new people in the offices, and same copier service. What is the percentage of ERROR? Who else would be appropriate for input, WHEN YOU LEAVE THE PATIENT OUT OF THE BILLING PROCESS, WHO COULD VERIFY THAT THE DOCTOR DID ALL THAT WAS ON THE BILL. The only person that could verify the patient in the Med-Legal, is the patient and the doctor. So when I saw for comment, in the case above, leads to file negligence, and patient applied medical treatment. And in the case above, the bate numbers and file numbers on multiple sheets on different dates show the patient is not who the file say they are. The other outside entities that you mentioned above, has NO RELATIONSHIP WITH THE PATIENT. They work the file, and sign under penalty of perjury, present it to the Judge, who signs off on the file. The file then is reviewed by the Auditor, auditor catches the error,

Anne Bazel Oct 15, 2018 a 3:10 pm PDT

I don't understand why there's still a debate. CCR 9793, as I understand, is produced to interpret and clarify Labor Code. It placed PTP at same level as QME/AME and specifically states PTP can write Med-Legal in addition to QME/AME. There's a modifier to use in case of Med-Legal written by PTP. Labor Code does not exclude PTP from writing Med-Legal report. What is the dilemma?

Stephanie Thomas Oct 16, 2018 a 2:10 am PDT

It is a possibility of multiple people in a case file, that went to the Judge, and the Judge signed off on it.

Brad Wixen Oct 15, 2018 a 3:10 pm PDT

The whole system is based on giving the Judge a choice as between the PTP and the PQME and case law states that they are of equal weight. If the PTP were denied the right to review records and comment on all issues, their role would be subverted by the Regs. The applicant would have no options and the system would fail.

M Oct 15, 2018 a 4:10 pm PDT

When the employer maintains control over injured Employee's medical treatment because the Employee can't get or doesn't know how to get a PTP other than US Healthworks, and US Healthworks PTP writes a CMR favorable to the Defendant, does the US Healthworks PTP bill for M-L report or just a PR4? Who knows - other than the US Healthworks PTP who bills it and the Defendant who pays it?

The problem is that what the Defendant pays for a favorable CMR are unknown, absent the PTP's bill and a Benefit printout. We only hear about the defenses the Defendant raises to an UNfavorable CMR.

Michael Costello Oct 15, 2018 a 5:10 pm PDT

A Med-Legal occurs when there is a medical dispute, a dispute occurs under 4060, 4061, or 4062, and per Code a QME or AME is secured first per 4062.1 and 4062.2, except under 4610. Can a PTP issue a ML, yes but it is at a request of a party usually to address the QME or AME. And, if PTP is being asked to comment on the dispute, both parties should be made aware of the request, including communications between party and doctor (PTP).

Jeffrey Estey Oct 15, 2018 a 11:10 pm PDT

It should be fairly obvious that a PTP cannot do a med-legal report. PTP's can and should make "medical determinations" regarding the issues. If a party then objects to a medical determination of a treating physician not covered by 4610, then the case can advance to the med-legal level to resolve the dispute created by the PTP's medical determination. A PTP cannot both create the dispute and resolve it.

Ron Perelman Oct 16, 2018 a 5:10 am PDT

The reality is that if you are the PTP and are requested to perform a ML report, you had better get authorization and the correct billing codes from the carrier, beforehand. What are the chances of that happening?
All of the above is theoretical, this is practical.

Robert Owens Oct 22, 2018 a 5:10 pm PDT

Chances of obtaining authorization and a billing code for a ptp med-legal are good at a msc before an ALJ.

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