1 Terminology (1-2 hrs.)

Question 1

Define QME

Answer 1

Qualified Medical Evaluator

Question 2

Define AME

Answer 2

Agreed Medical Evaluator. Any Dr can be agreed by both parties to examine for disability. AME may NOT be licensed QME!

Question 3

Define PTP

Answer 3

Primary Treating Physician.

Question 4

Define IW

Answer 4

Injured Worker

Question 5

Define QIW

Answer 5

QIW (Quilified Injured Worker) if they can not return to their job. They get $ to retrain called: Supplemental Job Displacement Benefits (SJDB), PAY OUT

Question 6

What constitutes an “injury”

Answer 6

a specific trauma or cumulative trauma that results in lost work time and/or interference with an employees ability to work

Question 7

Define AOE and COE

Answer 7

Arise out of Employment (AOE) + during the Course of Employment (COE) = Compensable work injury

Question 8

Define Aggravation vs. Exacerbation

Answer 8

An aggravation is a permanent increase in the severity of the preexisting condition.
An exacerbation is a temporary increase in symptoms that resolves, returning you to baseline.

Question 9

What is the no fault rule

Answer 9

The employer is required to pay benefits no matter who caused the injury.

Question 10

Liability

Answer 10

Liability for the injury “shall, without regard to negligence, exist against an employer for any injury sustained by his or her employees arising out of and in the course of employment and for the death of any employee if the injury proximately causes death,

Question 11

When is the Date of Injury (DOI)

Answer 11

the date the employee first suffered disability from the exposure

Question 12

Specific Injury

Answer 12

Occurs as a result of an incident or exposure which causes any disability or need for medical treatment

Question 13

Date of CT injury

Answer 13

both disability plus knowledge
“last injurious exposure”

Question 14

Cumulative Trauma (CT) examples

Answer 14

· Cumulative trauma disorders (CTDs)

· Repetitive Stress Injury (RSI)

· Overuse syndrome

· Repetitive motion disorders

Question 15

Define Medical Probability

Answer 15

Your opinion or conclusion based the probability 51% or greater.

“More likely than not”

Question 16

What probability is needed to determine AOE?

Answer 16

“more likely than not”

Question 17

Substantial medical evidence means

Answer 17

reasonable medical probability

“more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales

Question 18

What is the definition of permanent and stationary (P&S)?

Answer 18

A worker’s condition has reached Maximal Medical Improvement (MMI) and is unlikely to change substantially within the next year, with or without medical treatment

Question 19

Define impairment

Answer 19

impairment–deviation from pre-injury state; PTP, QME Rate Impairment in % Whole Person Impairment (WPI) with AMA 5th Edition Guides to the Evaluation of Permanent Impairment

Question 20

Define disability

Answer 20

disability–problems with function (work limits) due to impairment. Rated by the Disability Evaluation Unit (NOT the PTP or QME)

Question 21

Who calculates the disability rating?

Answer 21

A DEU rater (Disability Evaluation Unit)

Question 22

What are DEU forms 100 and 101?

Answer 22

100-Employee’s permanenet disability questionnaire; 101–Request for summary rating determination; both must accompany a QME report

Question 23

WPI refers to:

Answer 23

Whole Person Impairment uses the AMA 5th Ed. Guides

Question 24

What is the AMA 3% pain rule?

Answer 24

Physician can add a maximum of 3% to whole person impairment for pain greater than that normally associated with the injury

Question 25

What 8 categories of ADLs are taken into account to form an impairment rating?

Answer 25

1. self-care 2. communication 3. physical activity 4. sensory function 5. non-specialized hand activities 6. travel 7. sexual function 8. sleep

Question 26

What is the combined valued chart (CVC)?

Answer 26

chart in AMA guides designed to account for effects of multiple body parts impairments with a summary value that won’t exceed 100%

Question 27

Define UR

Answer 27

Utilization Review, they determine TREATMENT issues

Question 28

Define IMR

Answer 28

Independent Medical Review, then determine TREATMENT disputes

Question 29

What is form DWC1?

Answer 29

Work comp claim form used by injured employee to file a benefits claim

Question 30

What is the relationship between whole person impairment and work restrictions

Answer 30

Physician must qualify work restrictions based on what is impaired; there is no equivalency

Question 31

How long does a QME have to file a report

Answer 31

30 days for DOI after 1/1/94

Question 32

When can an injured worker choose their own Primary Treating Physician (PTP) if not predesignated?

Answer 32

30 days after DOI unless signed up for an HCO

Question 33

What is the pathophysiology of chronic pain?

Answer 33

process in which an injury produces one pathogenic mechanism, which in turn produces others so that the causes of pain change over time to include the loss of spinal inhibitory neurons leading to excitability and abnormal responsiveness in thalamic neuron

Question 34

What is form RU-90
RU-91?

Answer 34

RU-90 form filled out jointly by employee/insurance company that details job duties

RU-91 QME form for work restriction decisions

Question 35

Which 4 work factors are consistently highly associated with the onset of disabling pain?

Answer 35

1. job dissatisfaction 2. lack of support at work 3. stress 4. perceived inadequacy of income

Question 36

Define ‘Ex Parte’ communication

Answer 36

Ex Parte = excluding a party from communication. This is legally forbidden. The QME or AME should not talk to the attorneys or the carrier.

When you talk about details of the exam, you must include ALL Parties.

EXCEPTION for routine matters such as confirming appointments or that records have been sent, etc.

Question 37

In cases made Permanent & Stationary prior to 01/01/05, the PD (permanent disability) rating is based upon:

Answer 37

Subjective factors of disability, objective factors and work restrictions/preclusions.

Now we use AMA 5th Ed. Guided for whole person impairment (WPI%)

Question 38

Give objective findings examples

Answer 38

Lab tests, electrodiagnostic testing, x-rays and other imaging

Question 39

Who may perform a comprehensive medical-legal evaluation and report for the purposes of proving or disproving a contested claim?

Answer 39

PTP
QME
AME

Question 40

Medical-legal testimony means expert testimony provided by a physician at:

Answer 40

A deposition or
testimony WCAB hearing

Question 41

Just FYI

‘Types of Causation’

Answer 41

Direct Causation: The work exposures are directly responsible for the health outcomes

Contributing Cause: Several factors led to the disease; work exposure is one of these factors

Acceleration: The disease process is accelerated by virtue of work exposure. The date of onset of the disease is much sooner than would have occurred absent in the
absence of the exposure

Precipitation: The work exposure “precipitates” the manifestation of the illness. For example, an underling tendency or asymptomatic problem was present, but the work exposure causes it to clinically manifest

Aggravation: A medical condition may be present already, but work exposure makes it worse

Question 42

Define IMR

Answer 42

Independent Medical Review, a record review of patient to determine treatment issues.

Question 43

Presumptions

Answer 43

presumptions for some injuries and employment

presumption that the injury is accepted if the employer does not deny liability within a prescribed time period of receipt of the claim