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Thread Title: Advice - unpaid QME
Created On Wednesday February 11, 2009 9:16 PM

SFOJAM
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Wednesday February 11, 2009 9:16 PM

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I would appreciate the advice of the community on this one

I'm a newly appointed QME. I've done a handful of evals, all panel qme's, and have been compensated for precisely NONE of them. They are all 60 days+ old.

Phone calls to the carriers have been met correspondent ignorance necessitating large doses of sedatives.
(I knew better)

I've called the medical unit and left multiple messages with no response.
(cue the background music "all by myself...." )

Ironically, I still enjoy the work. I'd rather not work for free. I have several questions

1) Penalties and interest - 10% of the original bill after 60 days, what penalties apply in addition, if at all?
2) Does anyone have any good sample language for a letter to the payors? Is there any language that I can use on my letters that will prevent this happening in the future?
3) Is this worth writing a letter or should I just go find a lien claimant, if so , any recommendations in San Jose, CA?

Any and all advice would be appreciated.

Michaelb
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Wednesday February 11, 2009 10:05 PM

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How are you billing the reports?
Do you use a proof of service?
7% annual interest is applied additionally to the 10% penalty
The medical unit will be of no help. They will tell you "that is what the WCAB is for"

denisenewkirk
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Thursday February 12, 2009 12:29 PM

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SFO,

I would guess something is going wrong in your billing. It's unusual to not be paid AND to hear nothing back from the carrier. To whom are you sending the bills?

-------------------------
Denise
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rider001
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Thursday February 12, 2009 1:22 PM

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They should be paid within 60 working days. Adjusters are hard to get a hold of so i call bill review to see if (1) they have recieved it from the adjuster (2) if they have everything they need to review (3) if they have already recommended an allowance and the I/C has not cut the check. Bill review companies are much easier to get a hold and you should be able to get that information form the I/C. A suggestion is to compile a list of I/C and the bill review companies they use. Most of the time the hold up is with bill review who can't review a bill without a copy of the report. More often than not the adjuster keeps the report and does not forward it on as a delaying tactic, laziness, or it ended up with the socks the washer machine ate. If you don't mind the extra cost you could send it certified. Check with the bill review company. If they don't have it fax it to the adjuster for payment and keep the transmition confirmation. Here is contact information for a lien rep. in San Jose, Ca. mcarmenita@trshealth.net 408-836-1738. Hope this helped.

SFOJAM
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Thursday February 12, 2009 2:15 PM

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Thank you all for your replies.

MichaelB: Proof of service = fedex.

dnewkrk: Bills sent to adjuster consistent with service guidelines for unrepresented panel qmes

Rider: When I called one "bill review" service for SCIF, I got the complete runaround. (e.g. they didn't have a w-9 for me, they sent me a letter (never received), report wasn't filed (inaccurate)) It was so erroneous I didn't even know where to respond.

Ok. I will draft the nastiest letter I can, second notice, and fax it to adjuster and billing agency for payment with copy to WCAB. is there a specific department at WCAB responsible? e.g. audit or enforcement?

Michaelb
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Thursday February 12, 2009 5:47 PM

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WCAB is involved only after filing a lien.
You must wait 6 months from date of billing to file a lien.
You can try filing an audit referral ( go to the DIR home page to find out about audits)

appliedpsych
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Thursday February 12, 2009 7:17 PM

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Since you are new, are you sure you are providing all required entries, swearings under penalty of perjury, etc? They can hold you up if not. For example I learned quickly on my first QME report, which I was partially stiffed on, was that I did not put in the required billing reasoning on the first page of the eval. This is especially true if you are doing an ML104 level. I later found out that the reason I got stiffed and only partially paid was that I did not put the following up front, as required on the Regs.

BILLING METHOD
THIS IS A PANEL Q.M.E MEDICAL-LEGAL EVALUATION. THIS REPORT IS BEING BILLED UNDER ML104 OF REGULATION 9795. THIS IS DUE TO THE FOLLOWING QUALIFYING FACTORS: 1) Two or more hours of face-to-face time were spent with the patient. 2) Two or more hours of record review were required. 3) Two or more hours of medical research were required, to examine issues related to the clinical and medical-legal issues pertinent to the case. 4) Complex issues of permanent and stationary status, temporary disability, permanent disability, and related issues were addressed, upon request of the Insurance Carrier and case related Attorneys who agreed to the referral question. 5) Detailed analysis in relationship to the issue of good faith personnel action versus bad faith, temporary disability, and temporary versus permanent disability was carried out, including research into recent WCAB cases, and analyzing this case in light of recent changes in the WC system. (6) A complex and comprehensive psychological evaluation which was the primary focus of this medical-legal evaluation.

I don't know what you specialty is, or if your QME's were ML 104 level, but if they were, this could be part of your problem. Also if you do not list all required sworn statements correctly at the end, in the Physician Affadavit, the adjustor or payment reviewer can feel justified in withholding payment. Here's an example.

PHYSICIAN AFFIDAVIT
I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as the information I indicated I have received from others. As to that information, I declare under penalty of perjury that the information accurately describes the information provided to me, and, except as noted herein, I believe it to be true. I further declare under penalty of perjury that I personally performed the evaluation of the patient on **/**/**** at_________, and that except as otherwise stated herein, the evaluation was performed and the time spent performing the evaluation was in compliance with the guidelines, if any, established by the Industrial Medical Council or the administrative director pursuant to paragraph (5) of subdivision (j) of Section 139.2 or Section 5307.6 of the California Labor Code. I further declare under penalty of perjury that I have not violated the provisions of California Labor Code Section 139.3 with regard to the evaluation of this patient or the preparation of this report. I further declare under penalty of perjury that the name and qualifications of each person who performed any services in connection with the report, including diagnostic studies, other than clerical preparation, are as follows: No other persons were involved in this evaluation.

I herby declare under penalty of perjury that I have not violated Labor Code Section 139.3 in that I have not offered, delivered, received or accepted any rebate, refunds, commission, preference, patronage dividend, discount or other consideration whether in the form of money, or otherwise as compensation or inducement for any referred examination or evaluation.
Signed this

** day of ****** at ____________ County, California

Making sure that you follow all these steps should help you get paid.

I have never NOT been paid after that first screw up on my part in 1996.

SFOJAM
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Friday February 13, 2009 8:59 AM

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Michael B thanks again

AppliedPsych - this was an ortho eval. I have used similair legal disclosures in the course of my reports, I will compare vs. yours to ensure compliance.

Once again, thanks all for helping out a newbie.

appliedpsych
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Friday February 13, 2009 12:16 PM

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SFOJAM - I have also found it useful to mail or email these to adjustors when they are late making payment, or refusing penalty and interest.

Sorry, these links do not seem to be working, not sure why.

Edited: Friday February 13, 2009 at 12:24 PM by appliedpsych

Penalty Doc 3 New.pdf (213 KB)

Penalty Doc1.pdf (335 KB)

Penalty Doc1.pdf (335 KB)

Penalty Doc2.pdf (414 KB)

Penalty Doc2.pdf (414 KB)

Zorro
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Friday February 13, 2009 12:28 PM

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You must wait 6 months from date of billing to file a lien??

Z

Michaelb
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Friday February 13, 2009 1:03 PM

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4903.5 (b) Notwithstanding subdivision (a), any health care provider,
health care service plan, group disability insurer, employee benefit
plan, or other entity providing medical benefits on a nonindustrial
basis, may file a lien claim for expenses as provided in subdivision
(b) of Section 4903 within six months after the person or entity
first has knowledge that an industrial injury is being claimed.

appliedpsych
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Friday February 13, 2009 1:20 PM

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Let me try reposting those links.

Still not working.

Email me at appliedpsych@cox.net and I can attach there for you.

Edited: Friday February 13, 2009 at 1:21 PM by appliedpsych

Penalty Doc1.pdf (335 KB)

Penalty Doc2.pdf (414 KB)

Zorro
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Friday February 13, 2009 2:29 PM

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"You must wait 6 months from date of billing to file a lien."

I'm not a doctor or an attorney, and English is not my first language (I'm from Old California), but I would not equate "...may file a lien claim . . . within six months..." to "...must wait 6 months..." It's one or the other, and my money is on what the WCAB Rules say. As a general rule, never wait to file anything longer than you absolutely have to.

10770.5. Verification to Filing of Lien Claim or Application by Lien Claimant.

(a) Any lien claim or application for adjudication filed under Labor Code section 4903(b) shall have attached to it a verification under penalty of perjury which shall contain a statement specifying in detail the facts establishing that one of the following has occurred:

(1) Sixty days have elapsed since the date of acceptance or rejection of liability for the claim, or the time provided for investigation of liability pursuant to Labor Code section 5402(b) has elapsed, whichever is earlier.

(2) The time provided for payment of medical treatment bills pursuant to Labor Code section 4603.2 has elapsed.

(3) The time provided for payment of medical-legal expenses pursuant to Labor Code section 4622 has elapsed.

(b) In addition, if an application for adjudication is being filed, the verification under penalty of perjury also shall contain:

(1) A statement specifying in detail the facts establishing that venue in the district office being designated is proper pursuant to Labor Code section 5501.5(a)(1) or Labor Code section 5501.5(a)(2); and

(2) A statement specifying in detail the facts establishing that the filing lien claimant has made a diligent search and has determined that no adjudication case number exists for the same injured worker and same date of injury at any district office. A diligent search shall include contacting the injured worker, contacting the employer or carrier, or inquiring at the district office with appropriate venue pursuant to Labor Code section 5501.5(a)(1) or Labor Code section 5501.5(a)(2).

(c) The verification shall be in the following form:

I declare under penalty of perjury under the laws of the State of California that one of the time periods set forth in Rule 10770.5(a) has elapsed and, if an application for adjudication is being filed, that venue is proper as set forth in Rule 10770.5(b) and that I have made a diligent search and have determined that no adjudication case number exists for the same injured worker and the same date of injury. In determining that no adjudication case number exists for the same injured worker and the same date of injury, I have made a diligent search consisting of the following efforts (specify):
_____________________________________________________________
______________________________________________________________
______________________________________________________________
_____________________________________________________________

s/s______________________________________ on_____________________

Failure to attach the verification or an incorrect verification may be a basis for sanctions.

Z

Edited: Friday February 13, 2009 at 2:34 PM by Zorro

SFOJAM
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Friday February 13, 2009 3:05 PM

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Again, thanks all for your information.

Zorro, I would agree with your interpretation, the language creates a deadline, not a time limit prior to filing.

Again, I appreciate the collective experience and support in regards to this matter.

Michaelb
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Friday February 13, 2009 8:20 PM

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Appears the code has been corrected.
The only restriction appears that the proper time period to pay before being late is honored. ( 45-60 days)

SFOJAM
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Wednesday February 25, 2009 11:16 PM

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Just wanted to take a moment and post a last follow up.

Good news. All issues but one have been resolved.

Apparently, claims adjustors never really sent the bills to the billing center, so it was simply an issue of serving the report/bill plus a w-9 to four places, not three (worker, DEU, adjuster, billing center)

Once the billing center finds out that they have to pay pen/int they are rapid to cut the check. It's a strange sensation in medicine, I must admit. Generally, no one is in a rush to pay a doc.

Absolutely silly. Lesson learned. It's unfortunate, but you really can't take bureaucracy that seriously.

Again, many thanks again for helping a noob try to make a difference.

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