AB 404: Workers’ compensation: medical-legal expenses: fee schedule.
- Session Year: 2021-2022
- House: Assembly
- Latest Version Date: 2021-04-22
Existing law establishes a workers compensation system, which provides for comprehensive medical-legal evaluations to assist in the resolution of contested claims. Under existing law, fees for medical-legal evaluations are charged at a rate not to exceed a physicians regular fee, or the fee schedule set by the administrative director of the Division of Workers Compensation, whichever is lower. Existing law requires that the schedule set fees for procedures according to relative values and a conversion factor, allowing for modifiers, as specified. Existing law requires the medical-legal fee schedule to be revised at the same time the fee schedule for medical treatment is revised.
This bill would require that the medical-legal fee schedule be reviewed every 2 years, and updated if necessary, to increase the conversion factor by the percentage increase in the most recent federal Medicare Economic Index.
Existing law establishes a workers compensation system, which provides for comprehensive medical-legal evaluations to assist in the resolution of contested claims. Under existing law, fees for medical-legal evaluations are charged at a rate not to exceed a physicians regular fee, or the fee schedule set by the administrative director of the Division of Workers Compensation, whichever is lower. Existing law requires that the schedule set fees for procedures according to relative values and a conversion factor, allowing for modifiers, as specified. Existing law requires the medical-legal fee schedule to be revised at the same time the fee schedule for medical treatment is revised.
This bill would require that the medical-legal fee schedule be reviewed biannually, every 2 years, and updated if necessary, to increase the conversion factor by the percentage increase in the most recent federal Medicare Economic Index.
Existing law establishes a workers compensation system, which provides for comprehensive medical-legal evaluations to assist in the resolution of contested claims. Under existing law, fees for medical-legal evaluations are charged at a rate not to exceed a physicians regular fee, or the fee schedule set by the administrative director of the Division of Workers Compensation, whichever is lower. Existing law requires that the schedule set fees for procedures according to relative values and a conversion factor, allowing for modifiers, as specified. Existing law requires the medical-legal fee schedule to be revised at the same time the fee schedule for medical treatment is revised.
This bill would require that the medical-legal fee schedule be updated at least annually reviewed biannually, and updated if necessary, to increase the conversion factor by the percentage increase in the most recent federal Medicare Economic Index. The bill would require that the fee schedule not decrease in the event that the federal Medicare Economic Index decreases.
Existing law establishes a workers compensation system, which provides for comprehensive medical-legal evaluations to assist in the resolution of contested claims. Under existing law, fees for medical-legal evaluations are charged at a rate not to exceed a physicians regular fee, or the fee schedule set by the administrative director of the Division of Workers Compensation, whichever is lower. Existing law requires that the schedule set fees for procedures according to relative values and a conversion factor, allowing for modifiers, as specified. Existing law requires the medical-legal fee schedule to be revised at the same time the fee schedule for medical treatment is revised.
This bill would require that the medical-legal fee schedule be updated at least annually to increase the conversion factor by the percentage increase in the most recent federal Medicare Economic Index. The bill would require that the fee schedule not decrease in the event that the federal Medicare Economic Index decreases.
(a)The administrative director shall adopt a fee schedule for medical-legal expenses as defined by Section 4620, which shall be prima facie evidence of the reasonableness of fees charged for medical-legal expenses at the same time the administrative director adopts and revises the medical fee schedule pursuant to Section 5307.1 and, in any case, at least annually. every two years.
The schedule shall consist of a series of procedure codes, relative values, and a conversion factor producing fees which provide remuneration to physicians performing medical-legal evaluations at a level equivalent to that provided to physicians for reasonably comparable work, and which additionally recognizes the relative complexity of various types of evaluations, the amount of time spent by the physician in direct contact with the patient, and the need to prepare a written report.
The administrative director shall every two years review, and if necessary, update the schedule to reflect the rising costs of maintaining a medical practice by increasing the conversion factor and the per-page cost of reviewing records based on the percentage increase in the most current federal Medicare Economic Index.
(b)A provider shall not be paid fees in excess of those set forth in the fee schedule established under this section unless the provider provides an itemization and explanation of the fee that shows that it is both a reasonable fee and that extraordinary circumstances relating to the medical condition being evaluated justify a higher fee; provided, however, that in no event shall a provider charge in excess of their usual fee. The employer and employee shall have standing to contest fees in excess of those set forth in the fee schedule.
(c)In the event of a dispute between the provider and the employer, employee, or carrier concerning the fees charged, the provider may be allowed a reasonable fee for testimony if the provider testified pursuant to the employers or carriers subpoena and the judge or referee determines that the fee charged was reasonable and justified by extraordinary circumstances.
(d)(1)No provider may request nor accept any compensation, including, but not limited to, any kind of remuneration, discount, rebate, refund, dividend, distribution, subsidy, or other form of direct or indirect payment, whether in money or otherwise, from any source for medical-legal expenses if such compensation is in addition to the fees authorized by this section. In addition to being subject to discipline pursuant to the provisions of subdivision (k) of Section 139.2, any provider violating this subdivision is subject to disciplinary action by the appropriate licensing board.
(2)This subdivision does not apply to medical-legal expenses for which the administrative director has not adopted a fee schedule.
(a)The administrative director shall adopt a fee schedule for medical-legal expenses as defined by Section 4620, which shall be prima facie evidence of the reasonableness of fees charged for medical-legal expenses at the same time the administrative director adopts and revises the medical fee schedule pursuant to Section 5307.1 and, in any case, at least annually.
The schedule shall consist of a series of procedure codes, relative values, and a conversion factor producing fees which provide remuneration to physicians performing medical-legal evaluations at a level equivalent to that provided to physicians for reasonably comparable work, and which additionally recognizes the relative complexity of various types of evaluations, the amount of time spent by the physician in direct contact with the patient, and the need to prepare a written report.
The administrative director shall biannually every two years review, and if necessary, update the schedule to reflect the rising costs of maintaining a medical practice by increasing the conversion factor and the per-page cost of reviewing records based on the percentage increase in the most current federal Medicare Economic Index.
(b)A provider shall not be paid fees in excess of those set forth in the fee schedule established under this section unless the provider provides an itemization and explanation of the fee that shows that it is both a reasonable fee and that extraordinary circumstances relating to the medical condition being evaluated justify a higher fee; provided, however, that in no event shall a provider charge in excess of their usual fee. The employer and employee shall have standing to contest fees in excess of those set forth in the fee schedule.
(c)In the event of a dispute between the provider and the employer, employee, or carrier concerning the fees charged, the provider may be allowed a reasonable fee for testimony if the provider testified pursuant to the employers or carriers subpoena and the judge or referee determines that the fee charged was reasonable and justified by extraordinary circumstances.
(d)(1)No provider may request nor accept any compensation, including, but not limited to, any kind of remuneration, discount, rebate, refund, dividend, distribution, subsidy, or other form of direct or indirect payment, whether in money or otherwise, from any source for medical-legal expenses if such compensation is in addition to the fees authorized by this section. In addition to being subject to discipline pursuant to the provisions of subdivision (k) of Section 139.2, any provider violating this subdivision is subject to disciplinary action by the appropriate licensing board.
(2)This subdivision does not apply to medical-legal expenses for which the administrative director has not adopted a fee schedule.
(a)The administrative director shall adopt a fee schedule for medical-legal expenses as defined by Section 4620, which shall be prima facie evidence of the reasonableness of fees charged for medical-legal expenses at the same time the administrative director adopts and revises the medical fee schedule pursuant to Section 5307.1 and and, in any case, at least annually.
The schedule shall consist of a series of procedure codes, relative values, and a conversion factor producing fees which provide remuneration to physicians performing medical-legal evaluations at a level equivalent to that provided to physicians for reasonably comparable work, and which additionally recognizes the relative complexity of various types of evaluations, the amount of time spent by the physician in direct contact with the patient, and the need to prepare a written report.
The administrative director shall annually biannually review, and if necessary, update the schedule to reflect the rising costs of maintaining a medical practice by increasing the conversion factor and the per-page cost of reviewing records based on the percentage increase in the most current federal Medicare Economic Index. If the federal Medical Economic Index shows a decrease, the fee schedule shall not be reduced.
(b)A provider shall not be paid fees in excess of those set forth in the fee schedule established under this section unless the provider provides an itemization and explanation of the fee that shows that it is both a reasonable fee and that extraordinary circumstances relating to the medical condition being evaluated justify a higher fee; provided, however, that in no event shall a provider charge in excess of their usual fee. The employer and employee shall have standing to contest fees in excess of those set forth in the fee schedule.
(c)In the event of a dispute between the provider and the employer, employee, or carrier concerning the fees charged, the provider may be allowed a reasonable fee for testimony if the provider testified pursuant to the employers or carriers subpoena and the judge or referee determines that the fee charged was reasonable and justified by extraordinary circumstances.
(d)(1)No provider may request nor accept any compensation, including, but not limited to, any kind of remuneration, discount, rebate, refund, dividend, distribution, subsidy, or other form of direct or indirect payment, whether in money or otherwise, from any source for medical-legal expenses if such compensation is in addition to the fees authorized by this section. In addition to being subject to discipline pursuant to the provisions of subdivision (k) of Section 139.2, any provider violating this subdivision is subject to disciplinary action by the appropriate licensing board.
(2)This subdivision does not apply to medical-legal expenses for which the administrative director has not adopted a fee schedule.
(a)The administrative director shall adopt and revise a fee schedule for medical-legal expenses as defined by Section 4620, which shall be prima facie evidence of the reasonableness of fees charged for medical-legal expenses at the same time he or she the administrative director adopts and revises the medical fee schedule pursuant to Section 5307.1. 5307.1 and in any case, at least annually.
The schedule shall consist of a series of procedure codes, relative values, and a conversion factor producing fees which provide remuneration to physicians performing medical-legal evaluations at a level equivalent to that provided to physicians for reasonably comparable work, and which additionally recognizes the relative complexity of various types of evaluations, the amount of time spent by the physician in direct contact with the patient, and the need to prepare a written report.
The administrative director shall annually update the schedule to reflect the rising costs of maintaining a medical practice by increasing the conversion factor and the per-page cost of reviewing records based on the percentage increase in the most current federal Medicare Economic Index. If the federal Medical Economic Index shows a decrease, the fee schedule shall not be reduced.
(b)A provider shall not be paid fees in excess of those set forth in the fee schedule established under this section unless the provider provides an itemization and explanation of the fee that shows that it is both a reasonable fee and that extraordinary circumstances relating to the medical condition being evaluated justify a higher fee; provided, however, that in no event shall a provider charge in excess of his or her their usual fee. The employer and employee shall have standing to contest fees in excess of those set forth in the fee schedule.
(c)In the event of a dispute between the provider and the employer, employee, or carrier concerning the fees charged, the provider may be allowed a reasonable fee for testimony if the provider testified pursuant to the employers or carriers subpoena and the judge or referee determines that the fee charged was reasonable and justified by extraordinary circumstances.
(d)(1)No provider may request nor accept any compensation, including, but not limited to, any kind of remuneration, discount, rebate, refund, dividend, distribution, subsidy, or other form of direct or indirect payment, whether in money or otherwise, from any source for medical-legal expenses if such compensation is in addition to the fees authorized by this section. In addition to being subject to discipline pursuant to the provisions of subdivision (k) of Section 139.2, any provider violating this subdivision is subject to disciplinary action by the appropriate licensing board.
(2)This subdivision does not apply to medical-legal expenses for which the administrative director has not adopted a fee schedule.
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Date
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Status
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| Aug 11, 2022 | In committee: Held under submission. |
| Aug 26, 2021 | In committee: Held under submission. |
| Jul 5, 2021 | In committee: Referred to suspense file. |
| Jun 22, 2021 | From committee: Do pass and re-refer to Com. on APPR with recommendation: To Consent Calendar. (Ayes 5. Noes 0.) (June 21). Re-referred to Com. on APPR. |
| Jun 9, 2021 | Referred to Com. on L., P.E. & R. |
| Jun 2, 2021 | In Senate. Read first time. To Com. on RLS. for assignment. |
| Jun 1, 2021 | Read third time. Passed. Ordered to the Senate. (Ayes 79. Noes 0. Page 1726.) |
| May 24, 2021 | Read second time. Ordered to third reading. |
| May 20, 2021 | From committee: Do pass. (Ayes 16. Noes 0.) (May 20). |
| May 12, 2021 | In committee: Set, first hearing. Referred to APPR. suspense file. |
| Apr 29, 2021 | From committee: Do pass and re-refer to Com. on APPR. with recommendation: To Consent Calendar. (Ayes 13. Noes 0.) (April 29). Re-referred to Com. on APPR. |
| Apr 26, 2021 | Re-referred to Com. on INS. |
| Apr 22, 2021 | From committee chair, with author's amendments: Amend, and re-refer to Com. on INS. Read second time and amended. |
| Apr 15, 2021 | Re-referred to Com. on INS. |
| Apr 14, 2021 | From committee chair, with author's amendments: Amend, and re-refer to Com. on INS. Read second time and amended. |
| Apr 7, 2021 | Re-referred to Com. on INS. |
| Apr 6, 2021 | From committee chair, with author's amendments: Amend, and re-refer to Com. on INS. Read second time and amended. |
| Feb 12, 2021 | Referred to Com. on INS. |
| Feb 4, 2021 | From printer. May be heard in committee March 6. |
| Feb 3, 2021 | Read first time. To print. |
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Date
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Description
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Location
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Votes
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| Jun 1, 2021 | AB 404 Salas Assembly Third Reading | Assembly Floor |
Passed |
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Bill Author
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