Qualified Medical Examiner
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Subsequent Injury Benefits Trust Fund Evaluator
Phone: (833) 993-3900
The SIBTF Quarterback
April 2023
In the game of football, the quarterback is the first player to touch the ball. He must make quick decisions to pass, hand off to a runner, or take the ball and run.
Although football is only a game, the stakes can be considered high for the quarterback who is making split second decisions that can end in great success or painful failure.
Injured workers are not footballs by any stretch of the imagination and physicians are not players in a game. There are real stakes in the application for the Subsequent Injury Benefits Fund, with results that can be life-changing to an injured worker.
Chiropractors are a unique breed of physician that have proven suitable for this position. Experienced chiropractors are knowledgeable in not just evaluating the spine and extremities, but also in understanding the interplay and connections between many body systems and how they translate into disability. Chiropractors are well equipped to take a detailed and comprehensive history, and develop a strong rapport with their patients, facilitating referrals to the appropriate specialists in order to effectively develop the medical records and opinions required for their patient to qualify for the Subsequent Injuries Fund.
When faced with making game-changing decisions, who would you choose to quarterback your case, a rookie or a veteran?
The Updated MLFS
March 2023
With the onset of a new Panel QME fee schedule, new and surprising changes are happening in the way that PQME reports are being paid, and also how they are being written.
The adoption of the 2021 MLFS with a medical records page-count has effectively made medical information into a commodity. Insurance carriers now are on the hook at the rate of $3 per page for medical records over 200 pages for an initial QME evaluation. This means that in order to manage costs, the payors are cutting medical records down to only those that are critical and under 200 pages. The cost? Perhaps removing extraneous and unnecessary pages of records will save a few bucks from the med-legal bill, but what if medical records of a pre-existing condition were omitted? Could this mean that without substantial evidence for apportionment to other factors, the applicant's disability would be properly compensated? Impairment ratings without an operative report or imaging study certainly hold less weight and lose accuracy.
On the other side of the bench, with thinned out medical records, applicants may benefit from QME reports that make causation decisions easier. Applicants' history statements are uncontested when no medical records are available to corroborate them. More often than not, QMEs may need to rely on their gut than the available facts of a case.
If you were charged with a crime and standing trial, would you want your judge to have all the facts or make a gut decision?
When a QME declines to render an opinion, because the records are lacking, and then requests the additional medical records required to reach that opinion, this QME will almost certainly delay the resolution of this claim longer by 60+ days, depending on if and when the parties send the relevant records to the QME. This will undoubtedly hurt the injured worker seeking resolution to their claim. Insurance carriers, defense counsel, applicant attorneys and the QME are not experiencing pain and sleeplessness when an injured worker has a herniated disc. They are not facing lost wages. While the stakeholders play tug of war with pages and pennies, injured workers continue to suffer and the system drudges along at the same pace.
In order to reduce friction in the med legal system, I make it a rule to always include impairment ratings even with the most scarce medical records, with the disclaimer that more accurate opinions need more accurate medical information.
The unintended consequence of the new MLFS to lower costs may have handcuffed QMEs from doing their primary job - resolving claims and getting the appropriate benefits to the appropriate injured workers.