Lesson (2) =The Pawn: no

Payments EORs:

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.

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.

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.

Symbolic check list, in

line with mental

visualization The 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.

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

Adjuster States 0 Allowed Claim in

Litigation

Always Look to The Strongest Move

First

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.

§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

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.

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

Case Law

Adjuster States 0 Allowed Claim in

Litigation

Lesson (2) =The Pawn: no

Payments EORs: