Effective April 1, 2021, Medical- legal fee schedules for Agreed Medical Evaluator (AMEs) and Qualified Medical Evaluators (QMEs) are increasing from $625 to $2,015 with follow up exams at $1,316.25. There are limitations and numerous rules and regulations about review of records, missed appointments, supplemental reports, etc.

These medical fees are billed under “medical”, so they directly impact your X-Mod.

The last med-legal fee update was in 2006 and there were abuses of actual billings. It was time to set some rules. Besides, there are not enough doctors attracted to becoming a QME, so the wait time for scheduling exams and getting the reports often negated the entire reason for getting a QME in the first place.

What can an employer do to avoid the costly and time consuming QME process?

A QME is not a requirement. The treating doctor is required under Regulation § 9785 to complete a final report to address any permanent residuals (Permanent Disability or PD) and need for future medical care. This final report, PR-4, is a required document.

An employer can assist with medical management of your employee’s medical care by discussing recovery with your employee directly. Your goal is to be your employee’s advocate in the often slow and confusing Workers’ Comp medical treatment processes.

Here is what your discussion can look like…

• “How are you feeling?”

• “Are you getting better?”

If negative responses, then ask…

“Has your doctor discussed doing any testing?”  (Objective measurement with MRI’s, Nerve Conduction Tests, Scans, etc. can rule out medical diagnoses.)  

Or “Why don’t you talk to your doctor about other treatment options or specialist referral?”

Key indicators to look for with your claims:

• Months with no change in work status from the treating doctor

• Months with no change in treatment plan

• Months with no referral for objective testing or specialist opinion

 A frequent response that we hear from employees is that the doctor is waiting for the approval of the insurance company to proceed with testing or treatment.

Wait a minute! The claims adjuster has 5 days to respond to a doctor’s RFA - Request for Authorization. There are very specific rules and deadlines about this. Call the claims adjuster and ask why there is a delay in treatment authorization?

You can also ask your designated doctor or clinic to directly fax to you all work statuses and treatment requests. Then you can follow up with your employee and/or the claims adjuster to ensure treatment is progressing.

At ESM, your Claims Advocate is working with the you and adjuster to ensure prompt and appropriate treatment. If a QME becomes necessary, we ask the claims adjuster questions to ensure that the fees are kept to a minimum.

If you have questions about your employee’s medical treatment, please call your ESM Claims Advocate to discuss a strategy for achieving your employee’s recovery.

Mellen & Filippi Med-Legal Fee Schedule

Updated 4/1/2021