3. The Queen is defined as, Medical-Legal, WCAB and Petitions. The Queen is the most
powerful piece in the game, although many a games are won without it, one does not let it
go easily, as it can move like any piece on the board, except the knight, that can jump over
pieces. In workers comp, Medical-Legal services / disputes have a carve out, outside the
requirement of normal authorization, not subject to MPN rules and defenses, not subject to
the determination of the case-in-chief, nor subject to lien fees and time limits, making
medical-legal services the most powerful of all services in workers comp. Only a master
chessman or chess-woman, truly knows the importance of the Queen and how to maximizes
its function and power. Because of the many powerful tools in workers comp, I added to the
Queen, the WCAB, Appeals and Petitions, as the additional power tools of the
Queen. Petitions; the Director through the medical unit of the DWC is in control and the
watch dog of the UR, IBR, second review and IMR Process, of which several Petitions and
appeals can be filed, both defined and those yet to be defined. This process is to ensure the
King (burden of proof), is not compromised by fouls in the game. The Queen, also defines
the WCAB, with the massive influx of laws, a tremendous amount of case law should be
being created as to the interpretation and function of the new laws, of which is presently
lacking, thus the lack of the use of the queen.
The Queen is defined as, Medical-
Legal, WCAB and Petitions.
4. The Pawn is Defined as Billing
and EORS.
The Pawn is Defined as Billing and EORS. Each player
has eight pawns and although a pawn can only move one
space at a time, taking opponents only diagonal to it, it
protects the burden of proof (King) and if it reaches the
other side, it can be exchanged for any captured piece.
EORS and correct billing is extremely important, and
knowing what these EORS actually mean determines the
nature and extent of the game, move or interpret wrong
and the game is now long and drawn out, do it right and
the game is easily won.
5. EORS
• Authorization
• UR denials
• Services not certified
• MPN
• Denied Claim
• Provider Not Authorized (MPN)
• Paid Fee Schedule
• Carrier not admitting liability
• File closed determined non-compensable
• Etc.
6.
7. Symbolic check list, in
line with mental
visualizationThe key of using chess pieces as a symbolic check list, in line with mental visualization
is essential, as the biggest error for Providers is not knowing what they don't know,
massive unknown, unused laws and applications. Example: in every assertion the King
has to be addressed to ensure the game is not lost (i.e., the burden of proof), then
associated with other pieces , .i.e. billing, authorization etc. The Queen is medical-
legal, among other powers and the second most important piece, that always mandates
a mental check list on how it can be used to achieve the desired results, not limited to
authorization, denied claims, MPNs and petitions.
Mental visualization and symbolic check lists are a must, as each encounter, via phone,
settlements, documents, WCAB, applications, request for second review, and request
for authorizations, has limited application of words and documents in a short period of
time, thus easy to miss case changing issues. This is also essential in writing medical
reports for authorization issues and or medical-legal requests. No matter how much one
professes to know, the laws are too many to leave by chance of random recall without
the the possibility of missed essential issues.
8. 1. ID the Issue
2. ID the Services
3. ID the Path
4. Look to Queen to see if medical legal or petition
5. Look to King to see if can sustain the burden of
proof
11. The definition of "contested claim"
The definition of "contested claim" is varied, and can mean any of the
following: a rejected claim; a presumptively compensable claim; a
claim where temporary disability has not timely commenced or has not
issued a timely notice of delay; a claim where liability is accepted but
there are disputed medical facts.
If the PTP is requested by a "party" (applicant, Applicant Attorney,
Insurance), to do a P&S, a consultation , or any other report regarding
a "contested claim" , the PTP can then request (designate) and transfer
that request by a "party", to a another Provider (different specialty say a
psych which would include all necessary testing) to perform a Medical
Legal, and then those services are treated as a Medical- Legal and paid
as the same under the medical-legal fee schedule not the OMFS.
12.
13.
14.
15. §10451.1. Determination of Medical-
Legal Expense Disputes.
PETITIONS
The following procedures shall be utilized for the determination of medical-legal expense disputes.
(b) For purposes of this section:
(1) “medical-legal expense” shall mean any cost or expense incurred by or on behalf of any party for the
purpose of proving or disproving a contested claim, including but not limited to:
(A) goods or services expressly specified by Labor Code section 4620(a);
(B) services rendered by a non-medical expert witness;
(C) services rendered by a certified interpreter during a medical-legal examination; and
(D) all costs or expenses for copying and related services.
(2) “medical-legal provider” shall mean any person or entity that seeks payment for or reimbursement of
a medical-legal expense, other than an employee, a dependent, or the attorney or non-attorney
representative of an employee or dependent who directly paid for medical-legal goods or services.
(c) Medical-Legal Expense Disputes Not Subject to Independent Bill Review
16. Case Law
The definition of "contested claim" is varied, and can mean any of the
following: a rejected claim; a presumptively compensable claim; a
claim where temporary disability has not timely commenced or has not
issued a timely notice of delay; a claim where liability is accepted but
there are disputed medical facts.
If the PTP is requested by a "party" (applicant, Applicant Attorney,
Insurance), to do a P&S, a consultation , or any other report regarding
a "contested claim" , the PTP can then request (designate) and transfer
that request by a "party", to a another Provider (different specialty say a
psych which would include all necessary testing) to perform a Medical
Legal, and then those services are treated as a Medical- Legal and paid
as the same under the medical-legal fee schedule not the OMFS.
17. Case Law
En Banc Decisions of Warren Brower v David Jones
Construction; State Compensation Insurance Fund May 21,
2014 Case No: ADJ802221 (SJO 0258870) 79 Cal. Comp.
Cases 550
In a recent En Banc Decision the Court Held: Moreover, a
medical-legal expense is ordinarily allowable if it is capable of
proving or disproving a contested claim, if the expense was
reasonably necessary at the time incurred, and if the cost
incurred was reasonable. (§§ 4620 et seq., 5307.6.) The mere
fact that the parties had agreed to an AME in a particular
specialty does not mean that a party cannot reasonably obtain a
comprehensive medical-legal report from a treating physician
in the same or similar specialty
