11 Labor code sections relevant to QME’s 2 Flashcards
What is the process following a physician’s statement of reasons for non-appointment or termination?
Upon receipt of the physician’s response to the statement of reasons the administrative director reviews the decision regarding the non-appointment or termination of the physician and must notify the physician of the final decision within 60 days.
What agreements must the administrative director establish with medical evaluators?
The administrative director must establish agreements with qualified medical evaluators to ensure that cases assigned to them are evaluated in an expeditious manner allowing for timely assessments.
What is the time frame for assigning three-member panels of qualified medical evaluators?
When requested by an employee or employer the medical director must assign three-member panels of qualified medical evaluators within five working days after receiving the request.
What kind of cases are prioritized for panel assignment of qualified medical evaluators?
Preference in assigning panels will be given to cases in which the employee is not represented by legal counsel.
What happens if a panel of qualified medical evaluators is not assigned within a specific time frame?
If a panel is not assigned within 20 working days the employee may experience delays in the evaluation process which could impact their benefits and return-to-work process.
What section outlines the process for requesting a panel of qualified medical evaluators?
The process for requesting a panel of qualified medical evaluators is outlined in Section 4062.1.
What section outlines the appointment of the medical director responsible for assigning panels?
The appointment of the medical director who is responsible for assigning panels of qualified medical evaluators is outlined in Section 122.
What right does an employee have regarding medical evaluations?
An employee shall have the right to obtain a medical evaluation from any qualified medical evaluator of his or her choice within a reasonable geographic area.
What method does the medical director use to assign panels of qualified medical evaluators?
The medical director shall use a random selection method for assigning panels of qualified medical evaluators.
How does the medical director select qualified medical evaluators?
The medical director shall select evaluators who are specialists of the type requested by the employee.
What advice is given to the employee regarding the selection of a specialist?
The medical director shall advise the employee that he or she should consult with his or her treating physician prior to deciding which type of specialist to request.
What is the purpose of the form promulgated by the administrative director?
The form notifies the employee of the physicians selected for his or her panel after a request has been made pursuant to Section 4062.1 or 4062.2.
What information must the notification form include for each physician on the panel?
The form must include the physician’s name address telephone number specialty number of years in practice and a brief description of his or her education and training.
What sections are referenced in connection with employee requests for a physician panel?
The sections referenced are Section 4062.1 and Section 4062.2.
What is the role of the medical director in the selection of evaluators?
The medical director’s role is to select qualified medical evaluators randomly and ensure they are specialists relevant to the employee’s medical needs.
What is the significance of a ‘reasonable geographic area’ in the context of medical evaluations?
The term ‘reasonable geographic area’ ensures that the employee has access to qualified medical evaluators without being unduly burdened by travel or distance.
Why is it important for the employee to consult with their treating physician before selecting a specialist?
Consulting with the treating physician allows the employee to make an informed decision on which type of specialist is most appropriate for their medical evaluation needs.
What entitlements does an employee have regarding transportation expenses and temporary disability for medical examinations?
An employee is entitled to receive transportation expenses and temporary disability for each day necessary for the examination.
What must be stated clearly on the form regarding consulting rights for employees?
The form must clearly state: ‘You have the right to consult with an information and assistance officer at no cost to you prior to selecting the doctor to prepare your evaluation or you may consult with an attorney.’
What should employees be aware of if their claim goes to court?
If the claim goes to court the workers’ compensation administrative law judge will consider the evaluation prepared by the doctor selected by the employee to decide the claim.
What are the three criteria for selecting qualified medical evaluators?
- Conflict of Interest: The evaluator must not have a conflict of interest in the case as defined by regulations. 2. Certification: The evaluator must be certified. 3. Location: The evaluator must be located in a manner that meets regulatory requirements.
What does the term ‘Conflict of Interest’ refer to in the context of selecting evaluators?
In this context ‘Conflict of Interest’ refers to a situation where the evaluator may have a personal or financial interest that could compromise their objectivity or impartiality in assessing the employee’s claim.
Who compiles the list of qualified medical evaluators?
The medical director is responsible for compiling the list of qualified medical evaluators.
What is the importance of being certified as a medical evaluator?
Certification ensures that the evaluator possesses the necessary qualifications and adheres to the standards required to provide reliable and objective evaluations.
Can an employee choose any doctor for their evaluation?
An employee must select from a list of qualified medical evaluators compiled by the medical director ensuring that the chosen evaluator meets specific criteria.
What is the role of the administrative director in the evaluation process of an employee’s injury?
The administrative director is responsible for evaluating the employee in an appropriate specialty and at locations within the general geographic area of the employee’s residence.
How many locations can a qualified medical evaluator conduct evaluations at?
A qualified medical evaluator shall not conduct qualified medical evaluations at more than 10 locations.
Under what circumstances can an evaluator be suspended or terminated by the administrative director?
An evaluator can be suspended or terminated for failure to pay the fee required by the administrative director or for any other reason.
What action does the medical director take when there are not enough qualified medical evaluators of the appropriate type within the employee’s geographic area?
The medical director shall include sufficient qualified medical evaluators from other geographic areas to establish a three-member panel.
Who is responsible for paying travel costs for an evaluator selected from another geographic area?
The employer shall pay all necessary travel costs incurred when the employee selects an evaluator from another geographic area.
What is a qualified medical evaluator?
A qualified medical evaluator is a medical professional authorized to conduct medical evaluations pertaining to work-related injuries and can provide expert opinions on an employee’s medical condition and disabilities.
What must the medical director determine before assigning a type of specialist for an employee’s evaluation?
The medical director must determine that the evaluation requested by the employee is by a type of specialist that is appropriate for the employee’s injury.
What constitutes a ‘three-member panel’ in the context of medical evaluations?
A three-member panel consists of three qualified medical evaluators selected to collectively evaluate and provide a consensus on an employee’s medical condition related to a work injury.
What is the relevance of geographic area in the selection of medical evaluators?
The geographic area is relevant as the evaluation must take place within the general geographic area of the employee’s residence ensuring access to appropriate medical services.
When can the medical director expand beyond the local area for the selection of medical evaluators?
The medical director can expand beyond the local area when there are not enough qualified medical evaluators of the appropriate type within the employee’s residence area to form a three-member panel.
What is the role of the medical director appointed pursuant to Section 122?
The medical director is responsible for continuously reviewing the quality of comprehensive medical evaluations and reports prepared by agreed and qualified medical evaluators as well as the timeliness of these evaluations and reports.
What specific aspects are included in the medical director’s review?
The review includes a random sample of reports submitted to the division and all reports alleged to be inaccurate or incomplete by a party involved in the case for which the evaluation was prepared.
What must the medical director submit to the administrative director annually?
The medical director must submit an annual report summarizing the results of the continuous review of medical evaluations and reports along with recommendations for improving the medical evaluation system.
What is required before the administrative director adopts regulations following the medical director’s report?
A public hearing pursuant to Section 5307.3 is required before the administrative director can adopt regulations.
What are the potential contents of the regulations that the administrative director may adopt?
The regulations may include standards governing various aspects relevant to the medical evaluation process.
What is the maximum timeframe for initial medical evaluations to be prepared and submitted by qualified medical evaluators?
The maximum timeframe for initial medical evaluations to be prepared and submitted by qualified medical evaluators is no more than 30 days after the evaluator has seen the employee or commenced the medical evaluation procedure.
What are the circumstances under which an extension of the 30-day timeframe for medical evaluations can be granted?
Extensions of the 30-day timeframe can be granted in two cases: (1) when the evaluator has not received test results or consulting physician’s evaluations in time to meet the 30-day deadline and (2) to extend the 30-day period by not more than 15 days when the failure to meet the 30-day deadline was for good cause.
What constitutes ‘good cause’ for extending the 30-day deadline for submitting medical evaluations?
‘Good cause’ for extending the 30-day deadline includes: (1) medical emergencies of the evaluator or evaluator’s family (2) death in the evaluator’s family and (3) natural disasters or other community catastrophes that interrupt the evaluation process.
Who is responsible for developing regulations regarding the extension of the 30-day period for medical evaluations?
The administrative director is responsible for developing regulations governing the provision of extensions of the 30-day period for medical evaluations.
Can the 30-day period for medical evaluations be extended beyond 15 days for good cause?
No the 30-day period can only be extended by not more than 15 days for good cause.
What should medical evaluators do if they have not received necessary test results by the initial deadline?
If medical evaluators have not received necessary test results or consulting physician’s evaluations by the initial 30-day deadline they may apply for an extension of the deadline.
What is the role of qualified medical evaluators in the context of preparing medical evaluations?
Qualified medical evaluators are responsible for conducting thorough medical evaluations of employees and preparing reports within specified timeframes established by regulations.
Is there any provision for exceptions to the 30-day rule? If so what are they?
Yes exceptions to the 30-day rule include instances where test results or consulting physician’s evaluations are delayed and if there’s good cause as defined earlier.
What types of emergencies qualify as valid reasons for delay in submitting medical evaluations?
Medical emergencies affecting the evaluator or their family death in the evaluator’s family and natural disasters or community catastrophes qualify as valid reasons for delay.
What regulatory body oversees the timeframe and submission of medical evaluations?
The administrative director oversees the timeframes and submission of medical evaluations and is responsible for developing the necessary regulations.
What is the role of the administrative director concerning medical evaluators for unrepresented employees under Section 4062.1?
The administrative director is responsible for developing timeframes that govern the availability of qualified medical evaluators for unrepresented employees. These timeframes ensure that if an evaluator is not available within a specified period the employee is entitled to add a new evaluator to their panel at random. However the employee has the option to waive this right for a specified period afterward.
What are the procedures established for physicians evaluating permanent impairment and limitations resulting from an injury?
Physicians must follow procedures consistent with Sections 4660 and 4660.1 when evaluating the existence and extent of permanent impairment and limitations resulting from an injury.
What guidelines govern the determination of medical treatment disputes?
The determination of any disputed medical treatment issues must adhere to the guidelines set forth in Section 5307.27.
What procedures must be followed in the determination of compensability of psychiatric injury?
The procedures for determining the compensability of psychiatric injury must comply with Section 3208.3 and require specific established standards.
What rights does an employee have regarding evaluators if the scheduled evaluator is unavailable?
The employee has the right to add a new evaluator to their panel selected at random for each unavailable evaluator within the specified timeframe but may waive this right for a designated period.
What are the sections mentioned that relate to the evaluation of permanent impairment?
The relevant sections for evaluating permanent impairment are Sections 4660 and 4660.1.
What is the significance of Section 5307.27 in medical evaluations?
Section 5307.27 is significant because it outlines the procedures for resolving any disputes regarding medical treatment issues.
What does Section 3208.3 pertain to in the context of psychiatric injuries?
Section 3208.3 pertains to the procedures and requirements for determining the compensability of psychiatric injuries.
What manual is used for the diagnosis of mental disorders as mentioned in the provided text?
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders Third Edition-Revised (DSM-III-R) or other nationally accepted psychiatric diagnostic manuals.
What is the purpose of the guidelines mentioned in the document?
To establish minimum times required for patient contact during medical-legal evaluations that have not been defined and valued pursuant to Section 5307.6.
What is required for treatment procedures that have not been defined and valued?
They must adhere to the guidelines established for a range of time required for conducting the treatment procedures in consistency with regulations adopted pursuant to Section 5307.1.
Who has the authority to request evaluation procedures according to the provided text?
The Insurance Commissioner or the administrative director can request evaluation procedures.
What does Section 5307.6 pertain to in the context of medical-legal evaluations?
It pertains to the definitions and valuations of medical-legal evaluations establishing guidelines for the time required for patient contact.
What is necessary for evaluations not defined and valued by established sections in the document?
Such evaluations must still comply with minimum time requirements and possibly other regulations set by relevant authorities.
What does DSM-III-R stand for and what is its significance?
DSM-III-R stands for the Diagnostic and Statistical Manual of Mental Disorders Third Edition-Revised; its significance lies in being a standard classification system for mental disorders used by mental health professionals.
