QME Panels, Liens and Attorney Provider Collusion Top the List in Fresno

Frustrations with medical provider networks, QMEs, liens and some interesting attorney activity taking root in Fresno greeted administrative director of the Division of Workers’ Compensation Rosa Moran at Fresno’s City Hall. It was the fourth workers’ comp listening tour the administration has held this month. Roughly 130 people signed up to hear what defense attorneys, applicant attorneys, employers and medical providers say needs to be done to fix the system.

A growing frustration with lien claimants, the QME process, litigation and timely medical treatment dominated most of the proceedings. In particular, the growing number of lien claimants is seen by some defense attorneys as “the demise” of the workers’ comp system.

Dan O’Brien, a defense attorney, told the forum that the problem can be summed up in litigation costs involving lien claimants, “medical mills,” and deals made with applicant attorneys. He says that a cottage industry has sprung up between medical doctors, chiropractors and psychiatrists who refer patients back and forth to each other and subpoena records before even filing an application.

“The whole system is set up, so that if they have a lien claim, they will make as many appearances as possible and try to settle if they have $10,000 for $2,000,”O’Brien said, adding that, “If we could just follow the rules that we now have…” regarding proper and timely settlement, it would go a long way toward fixing the system. “It takes the Board’s time, and it’s just unfair,” he said.

Moran asked him if he knew why the Fresno Workers’ Compensation Appeals Board, despite not being part of Southern California, is showing an uptick in liens.

O’Brien said Los Angeles-based attorneys are getting together with doctors in the area to sign up patients, who in some cases don’t even know they have injuries. “I would say it’s five or six groups in town that are taking up 70% of my clients’ and 70% of the Board’s time.”

Defense attorney Richard Krum seconded the concern about what he called the “proliferation of lien claimants” for self-procured medical treatment. He says that the problem occurs when injured workers through their attorneys select doctors outside the network. The focus seems to be getting around the MPN requirements and treating injured workers in these so-called “medical mills,” as a way to make money.

“It’s very disturbing when you go to court and no longer is the focus on the injured worker. The injured workers… are now being pushed to the background and it’s all about litigation for the lien claimants,” Krum said.

Some speakers touched on MPNs-the good and the bad. Darlene Tiller, a registered nurse, said that employers that carefully select their doctors to create their own network, also known as boutique MPNs, have far more success in treating injured workers. She told AD Moran that boutique is the way to go.

“There’s no need for utilization review and there is no need for bill review because all the physicians on that particular network bill to the [fee] schedule,” Tiller said, adding that it’s distressing that so many insurance carriers feel the need to put every single treatment request through UR. “Why would you put something that cost less than $100 through utilization review when it’s going to cost you $100 to put it through there?”

Applicant attorney David Rockwell said that massive MPNs cause nothing but treatment delays because of the difficulty in actually finding a treating doctor in the network.

“It’s inadequate and often a sham…We get these lists of MPN doctors and we call and they’re not taking workers’ compensation cases. They don’t even know they’re on the list, and we can’t find proper care givers,” Rockwell said.

Panel QMEs spoke about the difficulties they have getting paid, sometimes for nothing more than minor administrative reasons. Or, they are simply ignored by the carriers. If they call to complain they run the risk of engaging in ex parte communication, so they end up having to submit liens. Attorneys chimed in other the months long delays their clients endure waiting for panels. They add that further delays can occur if a panel request form isn’t filled out correctly. After finally being told about the error, they’re then told they have to start over.

“If we go the panel route it’s taking six months in represented cases to get that list…By then the treatment that has been needed…the injured worker’s been waiting six months,” one attorney said.

Moran was happy to inform him that his information was a little “dated.”

“If there is anything we’ve been pushing on it’s the panel process. If we have panels that take six months to issue, we’re not serving anybody. When I last checked, it was a little bit over thirty days. They get 5,000 panels a month, so this is pretty amazing. It’s something we’re spending a lot of resources on,” Moran said.

As for submitting proper QME requests, Moran warned the attorneys in the room that leaving the filling out of that form to someone else is probably not in their best interests. Because of the Division’s limited resources, the forms that are filled out correctly are going to be dealt with first. “Non-compliant” requests get put to the side.

“I try to say this at every forum. If there is anything that you don’t want to delegate as an applicant attorney or a defense attorney, it’s that little panel request form,” Moran said. “I know that seems like a clerical procedure, but if you do it incorrectly you cost yourself a lot of months.”