Medicare Based Fee Schedule for Treating Physicians in  Workers CompensationJune 25, 2014

Via email:

To whom it may concern:

Re:  Medicare based fee schedule for treating physicians in workers compensation

My name is Ann Richmond and I own a billing company which bills for over 60 doctors that are providing for treatment of injured workers in California.  My company, Work Comp Medical Services, bills out approximately $600,000.00 combined per month.

As you are all most likely aware as of 1/1/14 the State adopted the Medicare based fee schedule for treating physicians involved in the care of injured workers.  Part of that fee schedule excludes payment for review of records (99358)  and reports.  (99358 is status B in Medicare which means that the fee is bundled into the Evaluation and Management code and is not separately payable.)  Doctors who care for Medicare patients are not required to produce reports and the patients are not involved in litigation of their care.

This is proving very difficult for many workers compensation doctors, attorneys and judges that I have heard from. Adjusters and legislators claim that the E&M codes are paying more than in 2013 and that this is an accommodation that is supposed to cover the review of records and reports.  In reality the new Medicare fee schedule no longer allows physician to bill under the consultation codes, i.e. 99241 to 99245 which paid a higher rate than the initial office visit codes which are the codes that are now required to be used.  So there is no increase for these E&M codes.

In San Diego I know of only one psychiatrist who is willing to accept new workers compensation cases at this time and he will only accept a few occasionally.  MPN’s are full of psychiatrists that will not accept workers compensation cases.

In most workers compensation cases there are legal issues with regard to causation, body parts, disability status and treatment requirements.  It is understandable that on a new injury there are not many records to review and not many issues to discuss and therefore on those cases payment for the face to face time and a short one page report can be subsumed by the payment for the face to face time.  Unfortunately most workers compensation cases that we see are in the throws of litigation with many prior doctors’ opinions, utilization review opinions, body part disputes, employment disputes, treatment disputes …..and the records received by the doctors are extensive.  The doctors want to come to a reasonable and substantial opinion but are now no longer compensated to do this.  I see many doctors no longer reviewing the records and just rendering a clinical opinion based solely on the evaluation of the injured worker.

As well, attorneys continue to request reports that address review of additional records without the injured worker being seen.  This poses a huge problem because the doctor is not afforded any compensation for this at all.  Some doctors are flat out refusing to do this and it is forcing attorneys to either request a panel QME to address the issue or it forces the attorney to file for a hearing to get an agreement with the defense to pay for supplemental reports by treating doctors.

Attached are several redacted letters from attorneys to doctors requesting such supplemental reports.  Some attorneys are suggesting that the treating doctor do a comprehensive medical legal report to address their requests.  This in my opinion is a waste of money and not technically legal if the treater is not the primary treater.

I am bringing this issue to your attention in hopes that the DWC will develop a workers compensation billing code for record review and will modify the existing workers compensation billing codes for reports in order to allow payment for requested record review reports.  It is hard to believe that a legal system that relies on medical reports does not allow payment for medical reporting.






Ann Richmond