Medical-Legal Process and Medical Bill Review
Process overview
Medical-legal reports drive permanent disability and apportionment. Candidates must understand the QME/AME system, the panel request process, qualified medical evaluator timelines, and the medical-legal fee schedule. Medical bill review applies the Official Medical Fee Schedule (OMFS) and RBRVS-based payment, plus utilization review and independent medical review for treatment disputes.
Traps
Questions often confuse AME (agreed medical evaluator) with QME (panel evaluator) and when each is used. Another trap is mixing medical-legal billing codes (ML-201 through ML-205) with treatment codes. Watch for apportionment rules under Labor Code section 4663 and 4664 and the difference between causation and apportionment.
Rule of thumb
An AME is used when the parties agree; a QME is selected from a panel when they do not. Worked example: if the parties cannot agree on an evaluator, the injured worker requests a QME panel; the evaluator's report must address apportionment separately for each body part.
Key concepts
Know ML-201 to ML-205 codes, OMFS, RBRVS, UR/IMR timelines, and QME panel procedures.