20250SB__066898AMD INTRODUCED 2025-02-20 AMENDED_SENATE 2025-04-24 2025 SB AMD Introduced by Senator Hurtado LEAD_AUTHOR SENATE Hurtado

An act to amend

Section 5307.6 of the Labor Code, relating to workers’ compensation. workers’ compensation 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 authorize the administrative director to adjust the fee

schedule every years based on an evaluation of certain medical practice costs, including increases in the conversion factor and the per-page cost of reviewing records, as specified. The bill would require the administrative director to update the fee

schedule at the time they adopt and revise the reasonable maximum fees for, among other things, drugs and pharmacy services provided to an injured employee. MAJORITY NO YES NO NO NO NO NO NO NO NO The people of the State of California do enact as follows:

SECTION

Section 5307.6 of the Labor Code is amended to read: 5307.6. (a)

(1) The administrative director shall adopt a fee

schedule for medical-legal expenses as defined by

Section that shall be prima facie evidence of the reasonableness of fees charged for medical-legal expenses. The

schedule shall be adopted and revised at the time the administrative director adopts and revises the medical fee

schedule pursuant to

Section 5307.1.

(2) The

schedule shall consist of a series of procedure codes, relative values, and a conversion factor producing fees that provide remuneration to physicians performing medical-legal evaluations at a level equivalent to that provided to physicians for reasonably comparable work, and that 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.

(3) The administrative director may adjust the fee

schedule every two years based on an evaluation of medical practice costs, including consideration of increases in the conversion factor and the per-page cost of reviewing records as informed by the most current 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) A provider shall not request or 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 that 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.