The Scope Of Discovery Of Med/Legal Charges Decided

In a time when the Board has established lien units, specifically to deal with liens, an appellate court has given some guidelines as to interpretation of Labor Code section 4628 in dealing with those liens.

The Court first indicated that 4628 was really an anti-ghostwriting statute. The statute was for the purpose of controlling the quality of the report. The statute enumerates the responsibilities of the signing doctor.  Subdivision (d) the Court indicated does not limit or regulate the amount of legitimate fees a doctor or clinic can charge.

When disputing these costs this opinion gave some guidelines as to what is discoverable from the entity involved. Defendants do not have an unfettered access to business records.

“ Defendant’s may only seek discovery of relevant and unprivileged information mat will assist them in determining the medical services performed by the physician, the amount of direct charges for me physician’s professional services, and the amount of costs related for related medical tests, clerical expenses and overhead.”

In interpreting this statute the opinion indicated that “…the statute merely limits the types of charges that can be reimbursed; it does not limit the amount of the charges that can be billed.” Nothing in 4628 (d) limits what can be charged and does not restrict a clinics ability to make a profit. It is up to the Board to determine what constitutes reasonable charges by factors such as those enumerated in Gould v. WCAB.

The Court indicated that Labor Code sections 4621,4622, 5307.1, and 5307.6 are the appropriate sections for the defendant to raise to challenge the reasonableness of the medical-legal charges. Once challenged, the clinic or doctor must provide sufficient justification by way of itemization under sections 5307.1 and 5307.6.  In determining what a defendant may be entitled to, the Court indicated that defendants do not have an unfettered right to books and records regarding the clinics overall business operation. The clinic does have a privacy right in financial and employment information unrelated to the preparation of the report. Tax returns are not discoverable.

“Defendants are entitled to relevant and unprivileged information that will assist them in determining (1) the medical services performed by the physician signing the report, (2) the amount of direct charges for mat physician’s professional services, and (3) the amount of the reasonable costs for lab exams, diagnostic studies, medical tests, and clerical expense related to producing the report.” It is then up to the Board to determine what is discoverable in order for defendants to determine the reasonableness of the charges.

Case: Ameri-Med V. W.C.A.B.

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

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