HOME PAGE

   
GO to Injured Worker Forum
Navigation:


ALL FORUM'S TOPICS OR LIENS TOPICS [ REFRESH ]
Thread Title: QME bill reduction
Created On Wednesday September 10, 2008 1:08 PM


Michaelb
Member

Posts: 187
Joined: Aug 2007

Wednesday September 10, 2008 1:08 PM

User is offline View thread in raw text format

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.

Reply
Quote
Top
Bottom



jonbrissman@verizon.net
Senior Member

Posts: 377
Joined: Oct 2003

Wednesday September 10, 2008 8:13 PM

User is offline View thread in raw text format

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

Reply
Quote
Top
Bottom



ltipton
Junior Member

Posts: 11
Joined: Sep 2006

Friday September 12, 2008 10:15 AM

User is offline View thread in raw text format

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.

Reply
Quote
Top
Bottom



Michaelb
Member

Posts: 187
Joined: Aug 2007

Friday September 12, 2008 11:12 AM

User is offline View thread in raw text format

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

Reply
Quote
Top
Bottom

FORUMS > LIENS [ REFRESH ]

FuseTalk 3.0 - Copyright © 1999-2002 e-Zone Media Inc. All rights reserved.
© 2013 WorkCompCentral Workers Compensation Forums