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Pay raises sought for medical examiners to curb comp system exodus

California medical examiner

A legislative effort to raise the compensation for qualified medical examiners in California aims to help quell the loss of doctors working on cases involving injured workers.

Qualified medical evaluators are physicians certified by the California Division of Workers Compensation Medical Unit to examine injured workers and determine their eligibility for benefits, with a panel of three QMEs assigned to review cases of injured workers when there are disputes with the treating physician’s diagnosis.

But a 2018 study by the California Workers’ Compensation Research Institute found a 20% drop in the number of such doctors since 2012.

“That’s why there is such a concerted effort now to reenvision and reset the medical fee schedule,” said Alex Swedlow, president of the Oakland, California-based institute. A “more equitable fee schedule” might help, he added.

QMEs are described in legislative documents for A.B. 1832 — introduced on July 11 and set for a hearing on Aug. 11 — as the “(linchpin) of the workers compensation system.” The bill would raise the comp medical-legal fee schedule for QMEs and require the state to periodically raise reimbursements for medical care and is noted in legislative documents as an “urgency bill” aimed to reverse the current situation: “an all-time low of QMEs in the system,” documents state.

“Simply put, if an injured worker’s claim is contested, their lives are at a standstill until they receive a QME evaluation,” according to bill documents. Assembly member Rudy Salas, D-Bakersfield, sponsor of the bill, did not respond to requests for comment.

Why so many QMEs have left the California system is a question is at the heart of an ongoing audit of the Department of Industrial Relations, initiated earlier this year by Assembly member Blanca Rubio, D-Baldwin Park, who wrote to the state’s Joint Legislative Audit Committee, chaired by Assembly member Salas, requesting a legislative investigation of current statutes regarding QMEs, the issue of supply-and-demand, and how the department communicates with insurers, among other issues.

In her letter dated Feb. 19, she described the estimated low number—2,500 in early 2019—of QME physicians working in the state as an “epidemic” as the demand for their services continue to rise: 135,000 evaluations requested in 2017 compared to 65,000 in 2006.

“The DWC has failed to revise or update the QME fee schedule since 2006 … as a consequence QME physicians have been leaving in droves and the QME system is woefully understaffed,” wrote Assembly member Rubio, who did not respond to requests for comment.

Meanwhile, the loss of QMEs in California is on a downward trend that has been at play for over a decade and was not curbed by the last raise in pay for doctors initiated in 2006, a department spokesman said.

The Division of Workers’ Compensation is aware that the numbers of qualified medical examiners have declined,” the spokesman wrote. “This is not a recent development. DWC increased the fee schedule in 2006 primarily for this reason, but it did not reverse the decline of QMEs. No empirical studies have been done specifically in regard to whether the fees are the issue.”

While other stakeholders say pay is a top concern, another issue has been the state failing to renew licenses for QMEs, according to attorney Nicholas Roxborough, a Los Angeles-based partner at Roxborough, Pomerance, Nye & Adreani LLP.

Mr. Roxborough represented several comp doctors who accused the Department of Industrial Relations in 2017 of relying on “underground regulations” to its medical billing rules to deny their reappointment as qualified medical evaluators. That case was settled in 2018.

“They left the system because they were kicked out,” said Mr. Roxborough, adding that many did not want to deal with the process. “QMEs said it seems like a mess.”

Doctors working as QMEs can make up to $50,000 a year, but that figure would be closer to $500,000 working for the private sector, he said.

Mr. Roxborough called the bill a “great start” and said the move would likely reverse the trend of doctors leaving the comp system.

“The QME community has been waiting for years for the DWC to update their regulations – to revisit this issue. If the word got out that you are at 2019 price points then yes, they will come back. It’s not rocket science.”



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