DWC Not Prepared to Honor the current QME Fee Schedule Stakeholder Agreement

In general it appears that after three months of negotiations DWC has decided to go its own way and ignore whichever parts of the Stakeholder Agreement it chooses.

-- Medical Records received by the QME 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 CSIMS 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 Gabor Vari, MD, CEO of California Medical Evaluators, was asked about ML 206 reports he stated that the above review of the issues was correct and that the provision for ML 206 reports was "too broad and open to abuse by carriers."

-- Indeed, Dr. 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 was 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!). 




  

Tid-bits of Hypocrisy (the first in a series about proposed reform in workers comp)

The first tid-bit of hypocrisy we'll discuss is paper size. Financial negotiations between Workers Compensation physicians represented by the California Society of Industrial Medicine and Surgery (CSIMS) and the California Division of Workers Compensation (DWC) focused on this issue.


The reason is that the doctors wanted a certain level of minimum reimbursement circa $3.00 per page whereas the insurance industry, in this case spoken for by DWC, wanted to pay less, in short, while their alleged aim was supposedly to update the fee schedule to enable enhanced recruiting of physicians, the insurance companies were not wild with joy about this avowed objective. Nonetheless, it was the physicians' understanding after stakeholder negotiations between CSIMS and DWC that a joint stakeholder agreement had been reached on a pay-for-page basis.

Not quite. During the negotiations CSIMS envisioned standard size pages measuring 8.5 x 11  inches. The doctors for whom CSIMS was negotiating were consequently bowled over when DWC let it be known that the DWC version of a page would measure 8.5 x 14 inches.

In essence the DWC recommendation amounts to an increase in insurance company income, denial of a modest raise for physicians, and a reduction in services for injured workers.

We understand that DWC wants to hear what the parties and the public think about this proposal and others (see newsletters to follow) --  if you have an opinion make it known to DWCForums@dir.ca.gov (10 July 2020 is the cutoff date). You should also copy gparisotto@dir.ca.gov, khagen@dir.ca.gov,  membership@csims.org, your assembly representatives and state senators.