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Replying to Thread: QME bill reduction
Created On Wednesday 10, September, 2008 1:08 PM by Michaelb


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Michaelb
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Posts: 187
Joined: Aug 2007

Wednesday September 10, 2008 1:08 PM

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What is the code that explains the criteria for reducing a QME bill?
I supported my billing in the first paragraph of the report.
The EOR states " Level of Medical/Legal report billed unsupported by content/purpose.

OMFS has rules that denial must be explained clearly and how it can be disputed.

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jonbrissman@verizon.net
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Wednesday September 10, 2008 8:13 PM

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The OMFS is immaterial, look at the Medical-Legal Fee Schedule (8 CCR Sect. 9795). Each subdivision, ML101 through ML106, has criteria or elements to be met. If you billed consistently with the criteria, it seems like the only way to reduce the fee would be to attack one of the elements as lacking or insufficient. Medical-legal charges tend to be straightforward.

I recall a case where a defendant challenged a QME's brief statement that there was no basis for apportionment as insufficient to count as a complexity factor under ML103. Defendant wanted to downcode the charge to ML102. A WCJ agreed, but a WCAB panel ruled that the single sentence was adequate and awarded compensation at the ML103 level.

You know the drill -- file a lien, argue with adjuster, bill review service, or defense attorney, and file a Declaration of Readiness to Proceed if you can't settle.

JCB

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ltipton
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Friday September 12, 2008 10:15 AM

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You may want to enlist the assistance of a CPC/collector that has heavy experience with WC/MLFS/OMFS/Labor Code to see what might be lacking in your report. If there is nothing lacking, they can help you come up with a strong appeal letter that might stand a good chance of getting your denial or downcode turned around and paid.

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Michaelb
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Posts: 187
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Friday September 12, 2008 11:12 AM

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My point is the review company did not note what the specific deficit is.

OMFS requires a clear reason. A generic one response for all does not work in trial.

The ML code does not point that out as it does in the OMFS

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