MEDICAL-LEGAL – EVERYTHING YOU NEED TO KNOW
Per the California Code of Regulations (CCR), Section 9793 (h), “Medical-legal expense” means any costs or expenses incurred by or on behalf of any party, for the purpose of proving or disproving a contested claim.
Per Labor Code Section 9795, below are the codes to use when billing for medical-legal services:
ML200 – Missed Appointment for a Comprehensive or Follow-Up Medical-Legal Evaluation.
You may bill for a missed appointment in any of the below circumstances:
- The injured worker does not show up for the evaluation.
- The interpreter does not show up for the evaluation, precluding the evaluation.
- The injured worker leaves the evaluation before the completion of the evaluation.
- The injured worker is more than 30 minutes late for the appointment.
- The appointment is canceled within six business days of the scheduled appointment date
If the physician produces a record review report within 30 days of the date of the missed appointment, reimbursement of $3.00 per page for any records reviewed in excess of 200 pages will be in order.
If fees for failed appointments and for late cancellations are incurred through the fault or neglect of the injured worker or his/her representative, the employer may seek to credit those charges against the injured worker’s award.
ML201 Comprehensive Medical-Legal Evaluation
- Includes all comprehensive Medical-legal visits in which the doctor sees the patient for the first time OR 18 months after the last med-legal evaluation.
- Fee includes review of 200 pages of records.
- Review of records in excess of 200 pages shall be reimbursed at the rate of $3.00 per page (MLPRR).
ML202 Follow-up Medical-Legal Evaluation.
- Occurs within 18 months of the date of a prior comprehensive med-legal
- Fee includes review of 200 pages or records; not previously reviewed
- Review of records in excess of 200 pages shall be reimbursed at the rate of
$3.00 per page (MLPRR).
ML203 Fees for Supplemental Medical-Legal Evaluations.
- Writing a report after receiving a request for a supplemental report from a party.
- Receiving records that were not available at time of the initial or follow-up
- Fee includes review of 50 pages of records.
- Review of records in excess of 50 pages shall be reimbursed at the rate of
$3.00 per page (MLPRR).
Fees will not be allowed under this section for supplemental reports: (1) following the physician’s review of information which was available in the physician’s office for review or was included in the medical record provided to the physician prior to preparing a comprehensive medical- legal report or a follow-up medical-legal report; or (2) addressing an issue that was requested by a party to the action to be addressed in a prior comprehensive medical-legal evaluation, a prior follow- up medical-legal evaluation, or a prior supplemental medical-legal evaluation.
Failure to issue a supplemental report upon request because of an inability to bill for the report under this code would constitute grounds for discipline by the Administrative Director or his or her designee.
ML204 Fees for Medical-Legal Testimony.
- Physician to be paid minimum of 2 hours.
- Time-based $113.75 for each 15 minutes.
- Reasonable preparation and travel time to be included.
- If cancelled fewer than 8 calendar days, physician to be paid a minimum of 1 hour.
ML205 Fees for Review of Sub Rosa Recordings.
- To be reimbursed at $81.25 for each 15 minutes.
- To be billed in addition to review of medical records as applicable.
- May charge for a supplemental report if applicable.
MLPRR Record Review.
- To be used to identify charges for review of records in excess of pages included in the medical-legal numerical billing codes
- Excess pages are billed at $3.00 per page
- Report must contain an attestation under penalty of perjury as to the total page count of
Per LC Section 9795 (d), the below modifiers are applicable to medical-legal evaluations, Procedure Codes ML201 through ML203:
-92 Performed by a primary treating physician.
It does not change value.
-93 Interpreter needed at time of examination.
Applicable only to ML201 and ML202.
Increases fee by 10%
-94 Performed by an Agreed Medical Examiner.
Increases fee by 35%
-95 Performed by a panel selected Qualified Medical Evaluator.
It does not change value
-96 Performed by a Psychiatrist or Psychologist
Psychiatric or psychological evaluation primary focus of the evaluation.
Increases fee by 100%
-97 Performed by a physician who is board certified in Toxicology
Toxicology evaluation is the primary focus of the evaluation
Increases fee by 50%
-98 Performed by a physician who is board certified in Medical Oncology
Oncology evaluation is the primary focus of the evaluation.
Increases fee by 50%
MEDICAL-LEGAL REIMBURSEMENT TIME FRAMES
California Code of Regulations Section 9794 (b) states “All medical-legal expenses shall be paid within 60 days after receipt by the employer of the reports and documents required by the administrative director unless the claims administrator, within this period, contests its liability for such payment”.
Labor Code Section 4622 (a)(1) (Labor Code 4622(a)(1)– establishes penalty and interest rates for failure to pay within the time frame.
“… within 60 days after receipt by the employer of each separate, written billing and report, and if payment is not made within this period, that portion of the billed sum then unreasonably unpaid shall be increased by 10 percent, together with interest thereon at the rate of 7 percent per annum retroactive to the date of receipt of the bill and report by the employer.”
Because third party administrators don’t usually pay for these self-executing penalty and interests, physicians should submit a bill for untimely payment (Penalty and Interests). Use this link to calculate penalty and interests.