In billing for evaluations of workers' compensation patients, health care providers should be very careful to ensure that they do not misrepresent themselves as a certified Qualified Medical Examiner (QME) on a medical legal evaluation or billing statement.
In addition, it is important to ensure that the bills for medical legal expenses have been reviewed so that the criteria for medical-legal billing has been met. A recent case shows how a report by two provider who were not properly certified QMEs led to criminal insurance fraud charges.
On May 7, 2019, psychologist Danita Stewart and Dr. Catalino
Dureza were charged for allegedly submitting fraudulent
insurance claims for Medical Legal Evaluations. They are presumed innocent and charges are not evidence.
Dr. Stewart,
a licensed psychologist, allegedly submitted 36 fraudulent insurance claims
between April 2015 and June 2015 to five different insurers for Medical Legal
Evaluations for a total of $90,714. A Medical Legal Evaluation is conducted to
evaluate an employee’s work-related injury and is governed by the California Labor Code.
Even though Dr. Stewart was a licensed
psychologist she was not certified as a Qualified Medical Examiner as
required to conduct and bill for Medical Legal Evaluations. Dr. Stewart
allegedly conducted these fraudulent evaluations at clinics in Fresno, Tulare,
and Kern Counties.
Dr. Dureza,
a licensed medical doctor, had obtained the proper certification to conduct and
bill for Medical Legal Evaluations, but his certification lapsed. Dr. Dureza
allegedly continued to conduct and bill for Medical Legal Evaluations, and once
he was recertified he conducted and billed for unauthorized Medical Legal
Evaluations. Between January 2014 and May 2015, Dr. Dureza allegedly submitted 17 fraudulent
insurance claims for Medical Legal Evaluations conducted in Fresno County to
five different insurers for a total of $16,292. This is not a large loss amount but shows that they will prosecute for amounts under $25,000. Dr. Dureza was charged with 17 felony counts of Insurance Code 1871.4(a)(1).
Whether or not someone is a QME is a public record so it appears the insurance carriers must claim that they paid these bills understanding that the providers were CMEs. I have seen cases where a biller has placed a QME, IME and AME near the providers' name, not realizing that there could be confusion on what type of report is being billed. The carriers have been aggressive about billings for these reports even though the providers could have billed for treatment without a QME certification.
Posted by Tracy Green, Esq.
