Medical Treatment Billing Analyzed In Writ Denied Case

This newsletter has not addressed Writ Denied cases in the past.  However, there was a recent case that may be beneficial in correctly evaluating the validity of a treatment lien.

Dr. Roback became the Applicant’s treating physician. “He referred Applicant to Lien Claimant Bio-Thermology for a thermogram, and t o Lien Claimant Center for Occupational and Sports Testing (Cost) for Arcon testing.” Defendants filed objections, including an objection for the reasonableness and necessity of the treatment performed.

The main issues were settled by C&R. At a lien hearing the WCJ ruled that Dr. Roback inappropriately billed as a medical-legal evaluator.  The WCJ made other rulings with which Lien Claimant took issue. In Lien Claimant’s Petition for Reconsideration, one of the issues presented was that the WCJ indicated mat no penalties were due under Labor Code section 4622 since Dr. Roback was a treating physician, rather man a medical-legal evaluator. This is an important issue to analyze when the Lien Claimant is requesting penalty and interest.

The WCJ also did not allow penalties and interest under Labor Code section 4603.2, stating Dr. Roback mislabeled his billings as medical-legal instead of as treatment bills. The WCJ also considered the billings excessive. The WCJ indicated mat the doctor could be paid for his reasonable treatment for the back injury, but mere would be no imposition of penalties and interest.  The WCJ disallowed the charge for the thermogram. Lien Claimant argued mat a Medical Advisory Opinion would allow the charges for the thermogram.  The Industrial Medical Council adopted its own opinion in 1994, “which stated that thermography ‘is an adjunctive diagnostic tool for nerve root injuries with radicular presentation where the patient is unable to undergo an EMG.” In this case, the Applicant had an EMG, making the need for the thermogram unreasonable. This Applicant also had an MRI. The WCJ concluded that the close proximity in time between the MRI and the thermogram made the thermogram unnecessary. Thus, when evaluating the payment for a thermogram, see if an EMG or MRI was previously performed.

The WCJ then evaluated the costs for Arcon testing. The WCJ used the Official Medical Fee Schedule to determine the proper code under which to bill. The WCJ used the schedule as a “guide”. Therefore, the Official Medical Fee Schedule should be used as a “guide” to determine payment.

The last issue the WCJ dealt with was the billing for medical-legal evaluator.  The WCJ determined this billing was unreasonable since the doctor was designated a treating physician.  Defendant’s failure to object to the charges did not convert Dr. Roback’s status to medical-legal evaluator.

Case: Roback V. W.C.A.B. (Banks)

Harvey Brown
3501 Jamboree Rd. Suite 602
Newport Beach, CA 92660

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