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AB-404 Workers’ compensation: medical-legal expenses: fee schedule.(2021-2022)

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Date Published: 04/22/2021 09:00 PM

Amended  IN  Assembly  April 22, 2021
Amended  IN  Assembly  April 14, 2021
Amended  IN  Assembly  April 06, 2021


Assembly Bill
No. 404

Introduced by Assembly Member Salas

February 03, 2021

An act to amend Section 5307.6 of the Labor Code, relating to workers’ compensation.


AB 404, as amended, Salas. Workers’ compensation: medical-legal expenses: fee schedule.
Existing law establishes a workers’ compensation system, which provides for comprehensive medical-legal evaluations to assist in the resolution of contested claims. Under existing law, fees for medical-legal evaluations are charged at a rate not to exceed a physician’s regular fee, or the fee schedule set by the administrative director of the Division of Workers’ Compensation, whichever is lower. Existing law requires that the schedule set fees for procedures according to relative values and a conversion factor, allowing for modifiers, as specified. Existing law requires the medical-legal fee schedule to be revised at the same time the fee schedule for medical treatment is revised.
This bill would require that the medical-legal fee schedule be reviewed every 2 years, and updated if necessary, to increase the conversion factor by the percentage increase in the most recent federal Medicare Economic Index.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

The people of the State of California do enact as follows:


 Section 5307.6 of the Labor Code is amended to read:

 (a) The administrative director shall adopt a fee schedule for medical-legal expenses as defined by Section 4620, which shall be prima facie evidence of the reasonableness of fees charged for medical-legal expenses at the same time the administrative director adopts and revises the medical fee schedule pursuant to Section 5307.1 and, in any case, at least annually. every two years.
The schedule shall consist of a series of procedure codes, relative values, and a conversion factor producing fees which provide remuneration to physicians performing medical-legal evaluations at a level equivalent to that provided to physicians for reasonably comparable work, and which additionally recognizes the relative complexity of various types of evaluations, the amount of time spent by the physician in direct contact with the patient, and the need to prepare a written report.
The administrative director shall every two years review, and if necessary, update the schedule to reflect the rising costs of maintaining a medical practice by increasing the conversion factor and the per-page cost of reviewing records based on the percentage increase in the most current federal Medicare Economic Index.
(b) A provider shall not be paid fees in excess of those set forth in the fee schedule established under this section unless the provider provides an itemization and explanation of the fee that shows that it is both a reasonable fee and that extraordinary circumstances relating to the medical condition being evaluated justify a higher fee; provided, however, that in no event shall a provider charge in excess of their usual fee. The employer and employee shall have standing to contest fees in excess of those set forth in the fee schedule.
(c) In the event of a dispute between the provider and the employer, employee, or carrier concerning the fees charged, the provider may be allowed a reasonable fee for testimony if the provider testified pursuant to the employer’s or carrier’s subpoena and the judge or referee determines that the fee charged was reasonable and justified by extraordinary circumstances.
(d) (1) No provider may request nor accept any compensation, including, but not limited to, any kind of remuneration, discount, rebate, refund, dividend, distribution, subsidy, or other form of direct or indirect payment, whether in money or otherwise, from any source for medical-legal expenses if such compensation is in addition to the fees authorized by this section. In addition to being subject to discipline pursuant to the provisions of subdivision (k) of Section 139.2, any provider violating this subdivision is subject to disciplinary action by the appropriate licensing board.
(2) This subdivision does not apply to medical-legal expenses for which the administrative director has not adopted a fee schedule.