Medical-Legal Reports in California Workers' Compensation

What Are Medical-Legal Reports?

Medical-legal reports are comprehensive evaluations performed by qualified physicians to determine disputed medical facts in California workers' compensation cases. These reports are governed by California Code of Regulations (CCR) Title 8, Sections 9793-9795 and are essential for proving or disproving contested claims regarding:

• Whether your injury is work-related (causation)
• The extent of your permanent disability rating
• Future medical treatment needs
• Work restrictions and limitations
• Apportionment of disability to prior injuries
• Need for vocational rehabilitation

Types of Medical Evaluators

Qualified Medical Evaluator (QME)

A physician certified by the Division of Workers' Compensation (DWC) Medical Unit to perform medical-legal evaluations. QMEs are assigned through a random panel selection process when the injured worker is unrepresented, or when parties cannot agree on an AME.

Agreed Medical Examiner (AME)

A physician mutually agreed upon by both the injured worker (through their attorney) and the claims administrator. AME evaluations receive a 25% higher fee than QME evaluations under the medical-legal fee schedule.

Primary Treating Physician (PTP)

Your treating doctor can also provide medical-legal reports, though their opinions may be subject to additional scrutiny as they have an ongoing treatment relationship with you.

Medical-Legal Fee Schedule (CCR 9795)

The fee schedule established under CCR Section 9795 became effective April 1, 2021 and provides prima facie evidence of reasonable fees for medical-legal evaluations.

ML102 - Basic Comprehensive Medical-Legal Evaluation

ML102 covers all comprehensive evaluations that do not qualify for complex (ML103) or extraordinary (ML104) status.

ML103 - Complex Comprehensive Medical-Legal Evaluation

To qualify for ML103, the evaluation must involve three or more complexity factors:

1. Two or more hours of face-to-face examination time with the injured worker
2. Two or more hours of medical record review by the physician
3. Two or more hours of medical research by the physician
4. Four or more hours spent on a combination of factors 1-3
5. Six or more hours total on all three factors combined

Important: The physician must specify which complexity factors apply in a separate section at the beginning of the report. For factor 3 (medical research), the physician must provide citations to sources reviewed.

ML104 - Extraordinary Circumstances Evaluation

ML104 applies in extraordinary circumstances, including:

• Four or more complexity factors from ML103 are present
• Multiple body parts being evaluated AND three or more ML103 complexity factors
• Parties agree in writing that extraordinary circumstances exist

Additional Billing Codes

• ML100: Missed appointment fee
• ML101: Follow-up evaluation (time-based at $62.50 per 15 minutes)
• ML105: Supplemental report preparation
• ML106: Medical-legal testimony ($250 per hour)

QME Evaluation Timeline

Requesting a QME Panel

Scheduling the Evaluation

Report Completion

Cancellation and Rescheduling

Report Content Requirements (Labor Code 4628)

Medical-legal reports must comply with specific requirements under Labor Code Section 4628. Failure to comply can make the report inadmissible as evidence and eliminate any liability for payment.

Physician Performance Requirements

• The signing physician must personally perform the evaluation
• Only nurses performing routine functions (blood pressure, vitals) may assist
• The physician must take a complete patient history
• The physician must personally review and summarize all prior medical records
• The physician must compose and draft all conclusions

Required Report Disclosures

• Date and location where the evaluation was performed
• Confirmation that the signing physician actually performed the evaluation
• Compliance with DWC guidelines for evaluation performance and time spent
• If not in compliance, detailed explanation of variance and reasons
• Name, qualifications, and role of any person (other than signing physician) who performed services

Declaration Under Penalty of Perjury

The evaluating physician must complete a declaration under penalty of perjury indicating the county where it was signed and dated, confirming that they personally performed all required elements of the evaluation.

Objection Procedures

Objecting to Medical Determinations (Labor Code 4062)

If either party objects to a medical determination by the treating physician, they must notify the other party in writing:

These time limits may be extended for good cause or by mutual agreement. Missing the deadline can result in losing your right to dispute the medical report.

Spinal Surgery Recommendations

The employer may object to a treating physician's recommendation for spinal surgery within 10 days of receiving the report.

Payment Timeline and Disputes (CCR 9794)

Payment Deadline

Contesting Payment

If the claims administrator contests all or part of a bill, they must within 60 days:

• Pay any uncontested amount
• Provide an Explanation of Review (EOR) detailing each objection
• Include the basis for objection to each contested procedure/charge
• If objecting to coding, provide both reported and suggested codes with rationale
• Describe any additional information needed for payment
• Include contact information for questions about the objection

Physician Response to Denial

Consequences for Non-Compliance

Remote Health (Telehealth) Evaluations

Under CCR Section 46.3, medical-legal evaluations may be conducted via video-conferencing when certain conditions are met:

• There is a disputed medical issue involving causation
• There is a dispute regarding termination of indemnity benefits
• Work restrictions are in dispute
• Both parties agree to the remote evaluation

These rules were updated in February 2023 to provide more flexibility for remote medical-legal evaluations.