11 Labor code sections relevant to QME’s 5 Flashcards
What happens after receiving the final comprehensive medical evaluation and summary form from the treating physician or qualified medical evaluator?
The administrative director shall recalculate the permanent disability rating according to Section 4660 and serve the rating the comprehensive medical evaluation and the summary form on both the employee and employer.
What is the role of a comprehensive medical evaluation in the context of permanent disability ratings?
A comprehensive medical evaluation from the treating physician agreed medical evaluator or qualified medical evaluator can resolve issues that may require an employer to take specific actions regarding permanent disability ratings.
What section of the law determines how the recalculation of the permanent disability rating is conducted?
The recalculation of the permanent disability rating is conducted according to Section 4660.
What parties must receive the recalculated permanent disability rating and related documents?
Both the employee and the employer must receive the recalculated permanent disability rating the comprehensive medical evaluation and the summary form.
What action must an employer take to provide compensation according to the text?
The employer must commence the payment of compensation or promptly commence proceedings before the appeals board to resolve the dispute.
What options do the employee and employer have regarding the findings and award related to compensation?
They can agree to stipulated findings and award as provided under Section 5702 compromise and release the claim under Chapter 2 commencing with Section 5000 of Part 3 or if the employee wishes commute the award under Chapter 3 commencing with Section 5100 of Part 3.
Before an appeals board approves an agreement or commutation what must they determine?
The appeals board must determine whether the agreement or commutation is in the best interests of the employee and whether the proper procedures have been followed in determining the permanent disability rating.
What is the role of the administrative director regarding the notification of the employee when service of any rating occurs?
The administrative director shall promulgate a form to notify the employee of the options specified the potential advantages and disadvantages of each option and the procedure for disputing the rating.
What sections outline the potential procedures for compromise and release of claims?
Chapter 2 commencing with Section 5000 of Part 3 outlines the compromise and release of claims.
What section outlines the commuting of awards for employees?
Chapter 3 commencing with Section 5100 of Part 3 outlines the commuting of awards.
What must be considered regarding the permanent disability rating before any agreement is made?
It must be ensured that the proper procedures have been followed in determining the permanent disability rating.
What kind of issues are mentioned as being related to the process described in the text?
No specific issues are given in the text but it is implied that various disputes or disagreements regarding the compensation process may arise.
What must occur before a declaration of readiness to proceed regarding permanent impairment and limitations resulting from an injury?
A medical evaluation by a treating physician or an agreed or qualified medical evaluator must first occur.
Can evaluations of permanent impairment and limitations from an injury be obtained outside the guidelines of Section 4062.1 or 4062.2?
No evaluations obtained in violation of the established prohibitions except evaluations by treating physicians shall not be admissible in any proceeding before the appeals board.
What is the primary role of the treating physician in the context of an injured worker?
The treating physician is primarily responsible for managing the care of the injured worker and must render opinions on all medical issues necessary to determine eligibility for benefits.
What are Section 4062.1 and 4062.2 related to in this context?
Section 4062.1 and 4062.2 are guidelines that outline the proper procedures for obtaining medical evaluations of permanent impairment and limitations.
What is the consequence of obtaining medical evaluations in violation of the established prohibitions?
Such evaluations shall not be admissible in any proceedings before the appeals board.
Who may render opinions on medical issues regarding an injured worker’s eligibility?
Opinions may be rendered by the treating physician or a physician designated by the treating physician following the rules set by the Administrative Director.
What is the role of the Administrative Director in the medical evaluation process?
The Administrative Director issues rules that guide the opinions on medical issues necessary for determining an injured worker’s eligibility.
What is the significance of a declaration of readiness to proceed in a workers’ compensation case?
It indicates that the injured worker is ready to move forward with their case particularly regarding disputes related to permanent impairment and limitations.
In what context would a treating physician’s evaluation be advisable?
A treating physician’s evaluation is critical to determine permanent impairments and necessary limitations following an injury to guide further proceedings.
What type of medical evaluations are specifically exempt from the admission prohibition?
Evaluations prepared by the treating physician or physicians are exempt from this prohibition.
What should be done if there is more than one treating physician for an injured worker’s care?
A single report shall be prepared by the physician primarily responsible for managing the injured worker’s care incorporating the findings of various treating physicians.
What happens if either party has an objection to a medical determination made by the treating physician?
The objecting party must notify the other party in writing of the objection within 20 days of receipt of the report if the employee is represented by an attorney or within 30 days if the employee is not represented by an attorney.
What specific conditions apply to employer objections regarding spinal surgery recommended by the treating physician?
Employer objections to the treating physician’s recommendation for spinal surgery are subject to a specific subdivision (b) following the denial of the physician’s recommendation as per Section 4610.
What timeframe is allowed for an employee to object to a decision made under Section 4610 that modifies a previous decision?
The text does not provide a specific timeframe for this objection; however past references outline that objections should typically be communicated in a timely manner.
What sections must be referenced when addressing objections related to medical determinations not covered by Sections 4060 4061 or 4610?
Objections must be about medical issues not covered by Sections 4060 or 4061 and that are also not subject to Section 4610.
Identify the roles of sections 4060 4061 and 4610 in the context of objections to medical determinations.
Section 4060 pertains to medical determinations regarding medical care; Section 4061 deals with issues related to medical treatment disputes; Section 4610 outlines the process for changes in medical treatment recommendations.
In what scenario would an employee be allowed a longer period to object to medical determinations?
An employee has a longer period to object (30 days) if they are not represented by an attorney compared to 20 days if they are represented.
What is the significance of the physician primarily responsible for managing an injured worker’s care?
This physician’s report is essential as it integrates and summarizes the findings from multiple treating physicians into a single comprehensive document.
What should be included in the report prepared by the primary physician?
The report should incorporate the findings of various treating physicians as part of the comprehensive assessment of the injured worker’s care.
What is the consequence if objections are not raised within the specified timeframes?
Failure to raise objections within the specified timeframes may result in the acceptance of the treating physician’s medical determination.
What must an employee do if they object to a treatment recommendation?
The employee must notify the employer of the objection in writing within 20 days of receipt of the decision.
Can the 20-day time limit for notifying the employer be extended?
Yes the time limits may be extended for good cause or by mutual agreement.
What happens if the employee is represented by an attorney regarding a disputed medical issue?
A medical evaluation to determine the disputed medical issue shall be obtained as provided in Section 4062.2 and no other medical evaluation shall be obtained.
What should an employer provide to an employee if they are not represented by an attorney?
The employer shall immediately provide the employee with a form prescribed by the medical director to request assignment of a panel of three qualified medical evaluators.
How is the medical evaluation obtained if the employee is not represented by an attorney?
The evaluation shall be obtained as provided in Section 4062.1 and no other medical evaluation shall be obtained.
What is the timeframe for an employer to object to a treating physician’s report recommending spinal surgery?
The employer may object to a report of the treating physician recommending spinal surgery within 10 days of receipt of the report.
If an employee is represented by an attorney what proceedings follow an objection to a treating physician’s report?
The parties will proceed according to the procedures outlined as they pertain to the representation of the employee by the attorney.
What sections govern the medical evaluations mentioned in this process?
Sections 4062.1 and 4062.2 govern the medical evaluations.
What is the significance of the ‘panel of three qualified medical evaluators’?
This panel is used to ensure that the evaluation of disputed medical issues is performed by multiple qualified professionals ensuring a fair assessment.
What is the requirement for selecting an orthopedic surgeon or neurosurgeon for a second opinion report in California?
The parties must reach an agreement on a California licensed board-certified or board-eligible orthopedic surgeon or neurosurgeon to prepare a second opinion report resolving the disputed surgical recommendation.
What happens if no agreement is reached within 10 days regarding the orthopedic surgeon or neurosurgeon selection?
If no agreement is reached within 10 days or if the employee is not represented by an attorney an orthopedic surgeon or neurosurgeon will be randomly selected by the administrative director to prepare a second opinion report.
What is the time frame for the examinations to be scheduled after the selection of the orthopedic surgeon or neurosurgeon?
Examinations shall be scheduled on an expedited basis.
What is the deadline for serving the second opinion report after receipt of the treating physician’s report?
The second opinion report shall be served on the parties within 45 days of receipt of the treating physician’s report.
If the second opinion report recommends surgery what is the employer’s obligation?
If the second opinion report recommends surgery the employer must authorize the surgery.
What actions must the employer take if the second opinion report does not recommend surgery?
If the second opinion report does not recommend surgery the employer shall file a declaration of readiness to proceed.
What is the employer’s liability regarding medical treatment costs for the disputed surgical procedure?
The employer shall not be liable for medical treatment costs for the disputed surgical procedure.
What is the role of the administrative director in the selection process for a second opinion orthopedic surgeon or neurosurgeon?
The administrative director randomly selects an orthopedic surgeon or neurosurgeon if the parties cannot agree and one of the parties is not represented by an attorney.
What qualifications must the orthopedic surgeon or neurosurgeon have for providing a second opinion in California?
The orthopedic surgeon or neurosurgeon must be California licensed and board-certified or board-eligible.
What is the importance of the second opinion report in the context of disputed surgical recommendations?
The second opinion report helps resolve disputes regarding surgical recommendations guiding the employer’s decision to authorize surgery or file a declaration of readiness.
What is required before undergoing a disputed surgical procedure according to the document?
The second opinion process must be completed before the disputed surgical procedure is performed.
Who is prohibited from having material affiliations with the second opinion physician?
The second opinion physician shall not have any material professional familial or financial affiliation with the employer the employer’s workers’ compensation insurer any officer director or employee of the employer’s health care provider or related entities or the physician’s medical group or independent practice association involved in the health care service in dispute.
What entities are mentioned that should not have affiliations with the second opinion physician?
- The employer and their workers’ compensation insurer. 2. Third-party claims administrators providing utilization review services. 3. Officers directors employees of the employer’s health care providers or insurers. 4. Physicians or medical groups involved with the healthcare services in dispute.
What type of expenses can be claimed if a procedure is performed before the second opinion process is completed?
A lien may be filed with the appeals board or as a self-procured medical expense.
What is the significance of having no material affiliations with the second opinion physician?
This ensures that the second opinion is unbiased and in the best interest of the patient maintaining the integrity of the medical decision and compliance with regulations regarding workers’ compensation cases.
What section is referenced for utilization review services?
Section 4610 is referenced for utilization review services.
What can occur in cases of temporary disability related to the disputed surgical procedure?
Periods of temporary disability resulting from the surgery can be claimed as a self-procured medical expense.
Why is the independence of the second opinion physician emphasized in the text?
Independence is emphasized to prevent any conflict of interest that could compromise the quality of the medical opinion or the patient’s care.
What actions can be taken if the second opinion process is not followed?
If the disputed surgical procedure is performed prior to the completion of the second opinion process a lien may be filed or expenses can be claimed retrospectively.
What guidelines dictate the affiliations acceptable for the second opinion physician?
The administrative director determines the acceptable affiliations to ensure an unbiased second opinion.
What is the role of the employer’s health care provider in relation to alternative services for an employee’s treatment?
The employer’s health care provider workers’ compensation insurer or third-party claims administrator may recommend an alternative service if applicable. This recommendation is sought to provide appropriate treatment options for the employee’s condition.
What should the employer provide regarding proposed treatments by the employee’s physician?
The employer should provide information about the development or manufacture of the principal drug device procedure or other therapy proposed by the employee or their treating physician as well as any alternative therapies recommended by the employer or related entities.
Who does the term ‘employee’ refer to in the context of the treatment review process?
In the context of treatment review the term ‘employee’ refers to the individual who is seeking treatment under the workers’ compensation system as well as the employee’s immediate family.
What restriction is placed on employers regarding agreed medical evaluators when the employee is not represented by an attorney?
If an employee is not represented by an attorney the employer is prohibited from seeking an agreement with the employee on an agreed medical evaluator. Additionally an agreed medical evaluator cannot prepare a formal medical evaluation on any issues in dispute.
