ADJ8671084 · May 31, 2024

The WCAB found that the dispute was over the reasonable value of Dr. Nathan's services and thus subject to Independent Bill Review, not WCAB jurisdiction, rescinding the WCJ's decision.

From the decision · page 2Based on our review of the record and applicable law, we find merit in defendant's contention that the WCAB lacks jurisdiction over this dispute because its essence is the reasonable value of Dr. Nathan's services, not coding or the rectitude of defendant's EORs as suggested by the WCJ. We also conclude that it is appropriate to allow this matter to proceed to IBR. Accordingly, we will rescind the WCJ's decision and replace it with a decision reflecting the above conclusions.

Defendant issued three Explanations of Review (EORs) with varying payment amounts, demonstrating the dispute was over the reasonable value of Dr. Nathan's services.

Favours Defendant prevailed

This showed the essence of the dispute was payment amount, not coding or procedural compliance, leading to IBR jurisdiction.

Evaluated applicant and provided a medical-legal report billed under ML-104 code.

From the decision · page 32. The Zenith Insurance Company (Zenith) retained Dr. Myron L. Nathan as its Qualified Medical Evaluator in psychiatry. The defense counsel's cover letter to the doctor states, "thank you for agreeing to evaluate the applicant in your capacity as a defense Qualified Medical Evaluator." The letter indicates Dr. Nathan should consider it "authorization to perform a complete medical evaluation," The letter requests Dr. Nathan address numerous issues, including AOE/COE and apportionment. (Correspondence from Chernow & Lieb dated March 23, 2018, [medical-legal provider's Exh. 1])

Labor Code section 4603.3

Labor Code section 4603.3 requires explanations of review to provide the basis for bill adjustments.

Applied to assess compliance of defendant's EORs.

From the decision · page 4A defendant is said to waive all objections to the medical-legal provider's billing if the defendant either "(I) failed to serve explanation of review (Explanation of Review) that complies with Labor Code section 4603.3 and any applicable regulations adopted by the Administrative Director and/or (II) failed to make payment consistent with that Explanation of Review." (8 CCR Section 10451.1(f)(1)(A)(i).) The [WCJ] finds that since the defendant did not serve any [EORs] that complied with Labor Code Section 4603.3, [defendant] waived all objection to the billing and that the matter is subject to the non-IBR process under 8 CCCR Section 10451.1(c)(1). The WCAB has jurisdiction over non-IBR disputes.

Labor Code section 4603.6

Labor Code section 4603.6 limits WCAB jurisdiction over medical-legal bill disputes and provides for Independent Bill Review.

Applied to determine proper forum for dispute resolution.

From the decision · page 7Labor Code section 4603.6(a) states: If the only dispute is the amount of payment and the provider has received a second review that did not resolve the dispute, the provider may request an independent bill review within 30 calendar days of service of the second review pursuant to Section 4603.2 or 4622. If the provider fails to request an independent bill review within 30 days, the bill shall be deemed satisfied, and neither the employer nor the employee shall be liable for any further payment. If the employer has contested liability for any issue other than the reasonable amount payable for services, that issue shall be resolved prior to filing a request for independent bill review, and the time limit for requesting independent bill review shall not begin to run until the resolution of that issue becomes final, except as provided for in Section 4622.

Labor Code section 4622

Labor Code section 4622 sets timeframes for payment of medical-legal bills.

Referenced in dispute over timely payment and penalties.

From the decision · page 2Defendant filed a timely petition for reconsideration of the WCJ's decision. Defendant contends that the WCAB lacks jurisdiction over this dispute because it involves the reasonable value of Dr. Nathan's services, that defendant paid Dr. Nathan's bill within the timeframes of Labor Code section 4622, that defendant's EORs complied with the requirements of Labor Code section 4603.3, that Dr. Nathan's claim is barred by his failure to request Independent Bill Review ("IBR") following defendant's response his request for second bill review, that Dr. Nathan's claim is barred by his failure to object within ninety days to defendant's initial EOR, that Dr. Nathan's claim is barred by the Statute of Limitations for lien claimants per Labor Code sections 4903(b) 4903.5, and that defendant is not liable for penalties, interest, sanctions, costs or attorney's fees.

Defendant's Explanations of Review (EORs) substantially complied with statutory requirements and communicated the dispute over reasonable value of services.