1 Terminology (1-2 hrs.) Flashcards
Learn the QME language
Define QME
Qualified Medical Evaluator
Define AME
Agreed Medical Evaluator. Any Dr can be agreed by both parties to examine for disability. AME may NOT be licensed QME!
Define PTP
Primary Treating Physician.
Define IW
Injured Worker
Define QIW
QIW (Quilified Injured Worker) if they can not return to their job. They get $ to retrain called: Supplemental Job Displacement Benefits (SJDB), PAY OUT
What constitutes an “injury”
a specific trauma or cumulative trauma that results in lost work time and/or interference with an employees ability to work
Define AOE and COE
Arise out of Employment (AOE) + during the Course of Employment (COE) = Compensable work injury
Define Aggravation vs. Exacerbation
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.
What is the no fault rule
The employer is required to pay benefits no matter who caused the injury.
Liability
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,
When is the Date of Injury (DOI)
the date the employee first suffered disability from the exposure
Specific Injury
Occurs as a result of an incident or exposure which causes any disability or need for medical treatment
Date of CT injury
both disability plus knowledge
“last injurious exposure”
Cumulative Trauma (CT) examples
· Cumulative trauma disorders (CTDs)
· Repetitive Stress Injury (RSI)
· Overuse syndrome
· Repetitive motion disorders
Define Medical Probability
Your opinion or conclusion based the probability 51% or greater.
“More likely than not”
What probability is needed to determine AOE?
“more likely than not”
Substantial medical evidence means
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
What is the definition of permanent and stationary (P&S)?
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
Define impairment
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
Define disability
disability–problems with function (work limits) due to impairment. Rated by the Disability Evaluation Unit (NOT the PTP or QME)
Who calculates the disability rating?
A DEU rater (Disability Evaluation Unit)
What are DEU forms 100 and 101?
100-Employee’s permanenet disability questionnaire; 101–Request for summary rating determination; both must accompany a QME report
WPI refers to:
Whole Person Impairment uses the AMA 5th Ed. Guides
What is the AMA 3% pain rule?
Physician can add a maximum of 3% to whole person impairment for pain greater than that normally associated with the injury
What 8 categories of ADLs are taken into account to form an impairment rating?
- self-care 2. communication 3. physical activity 4. sensory function 5. non-specialized hand activities 6. travel 7. sexual function 8. sleep
What is the combined valued chart (CVC)?
chart in AMA guides designed to account for effects of multiple body parts impairments with a summary value that won’t exceed 100%
Define UR
Utilization Review, they determine TREATMENT issues
Define IMR
Independent Medical Review, they determine TREATMENT disputes
What is form DWC1?
Work comp claim form used by injured employee to file a benefits claim
What is the relationship between whole person impairment and work restrictions
Physician must qualify work restrictions based on what is impaired; there is no equivalency
How long does a QME have to file a report
30 days for DOI after 1/1/94
When can an injured worker choose their own Primary Treating Physician (PTP) if not predesignated?
30 days after DOI unless signed up for an HCO
What is the pathophysiology of chronic pain?
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
What is form RU-90
RU-91?
RU-90 form filled out jointly by employee/insurance company that details job duties
RU-91 QME form for work restriction decisions
Which 4 work factors are consistently highly associated with the onset of disabling pain?
- job dissatisfaction 2. lack of support at work 3. stress 4. perceived inadequacy of income
Define ‘Ex Parte’ communication
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.
In cases made Permanent & Stationary prior to 01/01/05, the PD (permanent disability) rating is based upon:
Subjective factors of disability, objective factors and work restrictions/preclusions.
Now we use AMA 5th Ed. Guided for whole person impairment (WPI%)
Give objective findings examples
Lab tests, electrodiagnostic testing, x-rays and other imaging
Who may perform a comprehensive medical-legal evaluation and report for the purposes of proving or disproving a contested claim?
PTP
QME
AME
Medical-legal testimony means expert testimony provided by a physician at:
A deposition or
testimony WCAB hearing
Just FYI
‘Types of Causation’
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
Define IMR
Independent Medical Review, a record review of patient to determine treatment issues.
Presumptions
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
