New Medical-Legal Fee Schedule & Regulations Effective April 1, 2021, Including Fee Multipliers

The California Department of Industrial Relations, Division of Workers’ Compensation’s new Medical-Legal Fee Schedule (MLFS), which took effect on April 1st, 2021, will significantly increase the cost of medical-legal evaluations, and may have a wider impact on contested claims than initially indicated. The regulations apply to all evaluations taking place on or after April 1st, 2021, and include new multipliers that can further increase the cost of exams and evaluations.

The new and updated flat fees include:

ML-200: $503.75 for a Missed Appointment for a Comprehensive or Follow-Up Medical-Legal Evaluation. The language has been amended to include instances where the injured worker does not show up for the evaluation, the interpreter does not show up, the injured worker leaves the evaluation before completion, the injured worker is more than 30 minutes late and the QME is unable to continue, or the appointment has been cancelled within 6 days of the appointment date. An employer may seek credit for fees for failed appointments that are Applicant’s fault.
ML-201: $2,015.00 for a Comprehensive Medical-Legal Evaluation. Records over 200 pages shall be reimbursed at $3.00 per page. The physician must include a verification of number of pages reviewed.
ML-202: $1,316.25 for a Follow-Up Medical-Legal Evaluation within 18 months of the previous exam by the same physician. The fee includes review of 200 pages of records that were not reviewed as part of initial comprehensive evaluation or supplemental evaluation. Review of records over 200 pages shall be reimbursed at $3.00 per page. The physician must include a verification of the number of pages reviewed.
ML-203: $650.00 for a Supplemental Medical-Legal Evaluation, including review of up to 50 pages of records, and $3.00 per additional page. Fees will not be allowed under this section following the physician’s review of information that was previously available to the physician or for addressing an issue that was requested by a party to be addressed in a prior medical-legal evaluation. Failure to issue a supplemental report due to the inability to bill for the report is grounds for discipline.
ML-204: $455.00 per hour for Medical-Legal Testimony, including travel time. The physician is entitled to fees for time spent related to testimony including preparation and travel time. The physician shall be paid a minimum of 2 hours for deposition. If it is canceled less than 8 days before the date scheduled, the physician shall be paid one hour.
ML-205: $325.00 per hour for Review of Sub Rosa Recordings. The physician shall include a verification of time spent reviewing the sub rosa recordings. If the sub rosa recordings are received prior to the issuance of a pending report, the physician shall not also bill for a supplemental report.
ML-PRR: $3.00 per page for Record Review

The services described by Procedure codes ML 201 – ML 203 may be modified. The modifiers are not applicable to the per-page charges. The modifiers available are:

-92: Performed by PTP. For identification purposes only and does not change the value of the service.
-93: Interpreter needed for exam or other circumstances and need increases the time needed to conduct the exam. Requires a description of the circumstance and the increased time required for the exam as a result. The value for the procedure is modified by multiplying the normal value by 1.1. Applicable only to ML 201 and ML 202.
-94: Evaluation performed by an AME. The Value of the service is modified by multiplying the normal value by 1.35. If modifier -93 is also applicable for ML 201 or MO 202, then the value of the procedure is modified by multiplying the normal value by 1.45.
-95: Evaluation performed by a QME. For identification purposes only and does not change the value of the procedure.
-96: New modifier. For evaluation performed by psychiatrist or psychologist when psychiatric or psychological evaluation is the primary focus of the med-legal evaluation. The value of the procedure in modified by multiplying the normal value by .2. If modifier -93 is also applicable for ML 201 or ML 202, the normal value is modified by 2.10. If modifier -94 is also applicable to ML 201 or ML 202, the normal value is multiplied by 2.45.
-97: New modifier. For evaluation performed by a physician board certified in Toxicology, a QME in the specialty of Internal Medicine or a physician board certified in Internal Medicine when a Toxicology evaluation is the primary focus of the evaluation. The normal value of the procedure is multiplied by 1.50. If -93 is also applicable for ML 201 or ML 202, the normal value is multiplied by 1.60. If modifier -94 is also applicable for ML 201 or ML 202, the normal value is modified by 1.85. If modifier -93 and -94 are applicable for an ML 201 or ML 202, the normal value is modified by 1.95.
-98: New modifier. For evaluation performed by a physician who is board certified in Medical Oncology, a QME in the specialty of Internal Medicine or a physician who is board certified in Internal Medicine, when Oncology is the primary focus of the evaluation. The normal value of the procedure is multiplied by 1.50. If modifier -93 is also applicable for ML 201 or ML 202, the normal value is modified by 1.60. If modifier -94 is applicable for ML 201 or ML 202, the normal value is multiplied by 1.85. If -93 and -94 are also applicable for an ML 201 or ML 202, the normal value is multiplied by 1.95.

What this means for Defendants:
These new regulations and fees stand to significantly increase the costs for medical-legal evaluations. These fees arguably apply to charges by Primary Treating Physicians as well as PQMEs and AMEs in contested claims or where there is a disputed medical fact. In cases with hundreds or even thousands of pages of records, it is imperative to carefully consider what records to send for review. Defendants should meet with Applicant attorneys and agree on what records to submit, submit only those records relevant to the specific medical-legal issues, and be especially mindful to not submit duplicate records. The full impact of how these regulations will change med-legal discovery is not fully known, but it will clearly increase costs for the Defendants.

As always, if you have questions about what these regulations or other developments may mean for you or your case, please contact our offices.