A med-legal report is a medical-legal evaluation of an injured worker that is performed by an independent doctor because the worker or the insurance company disagrees with the report of the treating doctor.
Here, the term “treating doctor” refers to the physician who first diagnoses the worker to determine if there’s a connection between their medical condition and their job.
In California, when one of the parties wants to dispute the treating doctor’s determination, a new medical evaluation is necessary.
If the worker does not have an attorney, they can select a qualified medical evaluator or QME to perform this evaluation. If the worker has an attorney, the attorney and the claims administrator (usually the insurance company) may agree on a doctor called agreed medical evaluator or AME.
The QME or AME examines the worker and writes a report addressing the dispute. This report is called med-legal (or medical-legal) report.
The Importance of Accurate and Compliant Med-Legal Reports in California
Med-legal reports are complex documents that convey a wealth of information. For example, these are the details that a medical-legal report should include in California (where applicable):
- The date of the examination;
- The history of the injury;
- The patient’s complaints;
- A listing of all information received in preparation of the report or relied upon for the formulation of the physician’s opinion;
- The patient’s medical history, including injuries and conditions, and residuals thereof, if any;
- Findings on examination;
- A diagnosis;
- Opinion as to the nature, extent and duration of disability and work limitations, if any;
- Cause of the disability;
- Treatment indicated, including past, continuing and future medical care;
- Opinion as to whether or not permanent disability has resulted from the injury and whether or not it is stationary. If stationary, a description of the disability with a complete evaluation;
- Apportionment of disability, if any;
- A determination of the percent of the total causation resulting from actual events of employment, if the injury is alleged to be a psychiatric injury;
- The reasons for the opinion; and
- The signature of the physician.
More generally, medical-legal records in California must comply with the provisions of Labor Code section 4628, which can be accessed on this link.
Accurate and compliant med-legal reports are extremely important for all parties involved. They help ensure that workers get proper care and insurance companies pay fair settlements only when necessary.
As for QMEs or AMEs, a medical-legal report that fails to comply with all applicable regulations may have serious consequences, ranging from denied claims and inaccurate reimbursements to civil penalties and suspensions.
Practice IQ: Med-Legal Reporting Services in California
At Practice IQ, we have made it our mission to take care of the administrative side of medical-legal reports and billing so you can focus on what you do best.
We are located in Pomona, California, and serve clients all over the Golden State. Contact us today by telephone (424-433-5704) or email (piqusinfo@practiceiqusa.com), or fill out the contact form to learn more about our services.
