3. Ethical Standards 3 Flashcards
How soon must an evaluator notify relevant parties of a conflict of interest upon becoming aware of it?
An evaluator must notify the relevant parties within five business days of becoming aware of the conflict of interest.
Who should receive the notification of a disqualifying conflict of interest?
The notification should be sent to the injured worker the claims administrator or the employer and their respective attorneys if applicable.
What is the protocol for evaluators who have a disqualifying conflict of interest?
Evaluators with a disqualifying conflict of interest are required to notify all relevant parties in writing and disclose the nature of the conflict.
What constitutes a ‘disqualifying conflict of interest’?
A disqualifying conflict of interest includes relationships or circumstances that impair the evaluator’s impartiality such as familial ties financial interests or ethical issues linked to a person or entity involved in the claim.
What is the procedure to follow whenever a Medical Qualified Evaluator (QME) notifies the parties of a conflict without declining to perform the evaluation?
The parties shall follow the procedures set out in section 41.6 of Title 8 of the California Code of Regulations.
In what situation is an injured worker or claims administrator entitled to a replacement QME?
An injured worker or claims administrator is entitled to a replacement QME or in represented cases a replacement panel pursuant to section 31.5 of Title 8 of the California Code of Regulations.
What must the evaluator do if an injured worker is not represented by an attorney and a conflict arises?
The evaluator shall fax a copy of the notice of conflict to the Medical Unit of the Division of Workers’ Compensation at the same time it is sent to the parties.
Who must be notified in cases involving a potential disqualifying conflict of interest with a specific evaluator?
Any injured worker claims administrator or if none the employer including his or her attorney who knows of or becomes aware of a potential disqualifying conflict of interest must notify the relevant parties.
What section of the California Code of Regulations defines the procedures related to conflicts of interest for evaluators?
The procedures related to conflicts of interest for evaluators are defined under Title 8 specifically section 41.6.
What is the definition of a disqualifying conflict of interest in the context of a QME?
A disqualifying conflict of interest is a situation in which an evaluator has a potential bias or prior relationship that could affect the objectivity of the medical-legal examination and report.
What should a party do if they are aware of a conflict of interest with their selected QME?
The party should notify the relevant parties including a request for a replacement QME if necessary.
What is the role of the Medical Unit of the Division of Workers’ Compensation in the conflict notification process?
The Medical Unit of the Division of Workers’ Compensation receives notices of conflicts from evaluators when the injured worker is not represented by an attorney.
What are the implications of a party not following the outlined procedures in case of a conflict with the evaluator?
Failing to follow the outlined procedures may lead to delays in the evaluation process potential legal complications and issues with the validity of the evaluation.
In what context does section 31.5 of Title 8 apply to the QME process?
Section 31.5 of Title 8 applies to cases where a replacement QME or replacement panel is necessary particularly in represented cases.
What is the deadline for notifying the selected evaluator about a potential conflict of interest?
The selected evaluator must be notified in writing at the earliest opportunity and no later than within five (5) business days after becoming aware of the potential conflict.
What information must be included in the notice of potential conflict to the evaluator?
The notice must include the person with whom the alleged conflict exists and the nature of the conflict.
What is required to be done with the notice sent to the evaluator?
A copy of the notice shall be served on the opposing party at the same time it is sent to the evaluator.
What does the evaluator do upon receiving the conflict notice?
The evaluator reviews the information provided and determines whether a disqualifying conflict exists.
What happens whenever a disqualifying conflict of interest is identified by an Agreed or Qualified Medical Evaluator?
Whenever a disqualifying conflict is identified the parties shall follow specific procedures for handling the situation.
Does the occurrence of a disqualifying conflict of interest affect evaluations that have already been performed?
Yes even if the conflict arises after the evaluator has conducted initial or follow-up evaluations the conflict must be addressed.
What is the purpose of informing the evaluator about the potential conflict of interest?
To enable the evaluator to determine whether the alleged disqualifying conflict exists.
What is meant by ‘disqualifying conflict of interest’?
A disqualifying conflict of interest is a situation where the evaluator has a relationship or interest that may prejudice their ability to conduct an unbiased evaluation.
What should parties do after being informed about a disqualifying conflict of interest?
The parties shall adhere to established procedures following the notice of conflict.
What section of the California Code of Regulations discusses the evaluator’s disqualification from proceeding?
Section 41.5e of Title 8 of the California Code of Regulations discusses the evaluator’s disqualification from proceeding.
What is the timeframe within which parties must obtain a new evaluator after receiving a notice of conflict?
Parties must obtain a new evaluator within five (5) business days of receipt of the evaluator’s notice of conflict.
What is the procedure for obtaining a new evaluator if the injured worker is not represented by an attorney?
If the injured worker is not represented by an attorney the parties shall obtain a new evaluator by following the procedure provided under section 31.5 of Title 8 of the California Code of Regulations.
What must happen when the injured worker is represented by an attorney regarding the evaluator’s conflict?
When the injured worker is represented by an attorney each party must notify the evaluator and the opposing party in writing of their decision to either waive the conflict or to object to the evaluator based on the evaluator’s conflict.
What is a QME?
A QME (Qualified Medical Evaluator) is a medical professional qualified to evaluate injured workers and provide opinions regarding their medical condition and the extent of their injuries.
What happens if there is a conflict with the current evaluator?
If there is a conflict with the current evaluator a replacement QME or a replacement QME panel may be issued when necessary.
What should each party do in case of an evaluator’s conflict if both sides are represented?
If both sides are represented each party should notify the evaluator and the opposing party in writing regarding their decision to waive the conflict or object to the evaluator.
What should parties do if they object to an evaluator due to a conflict?
The parties shall obtain a new evaluator by following the procedures provided in Labor Code section 4062.2 and section 31.5 of Title 8 of the California Code of Regulations.
What is required for a conflict of interest waiver in a represented case?
A waiver of a conflict of interest is valid only if the general nature of the conflict is disclosed in writing and the document includes a signed statement from each party indicating that they understand the evaluator has a conflict of interest they understand the nature of the conflict and they wish to waive the opportunity to obtain another evaluator.
What is the significance of an attorney’s signature in the context of waiving a conflict of interest?
The signature of an attorney shall have the same effect as the signature of the party represented by the attorney provided that a copy of the document signed by the attorney is served on the represented party by the attorney or by any other party or attorney.
What is Labor Code section 4062.2 concerned with?
Labor Code section 4062.2 outlines the procedures for obtaining a new evaluator in cases where there is a conflict regarding the existing evaluator.
Where can one find the regulations related to evaluator conflicts in California?
The regulations related to evaluator conflicts in California can be found in section 31.5 of Title 8 of the California Code of Regulations.
In the context of conflict waivers what must be included in the written document?
The written document must include the general nature of the conflict a signed statement from each party acknowledging their understanding of the conflict and their desire to waive the opportunity to obtain another evaluator.
What is the duty of the attorney regarding signed documents in relation to the party-client?
The attorney has a duty to serve a copy of the signed document on the party-client.
Who determines disputes over conflicts of interest of an evaluator in relation to evaluation reports?
Disputes over whether a conflict of interest of an evaluator may affect the integrity and impartiality of the evaluator with respect to an evaluation report and any dispute over waiver of an evaluator’s conflict shall be determined by a Workers’ Compensation Administrative Law Judge.
What is the maximum value of gifts that a physician acting as an Agreed Medical Evaluator or Qualified Medical Evaluator can accept from a single source in a twelve-month period?
A physician reporting as an Agreed Medical Evaluator or a Qualified Medical Evaluator shall not accept gifts that have a total fair market value in the aggregate of three hundred sixty dollars ($360) or more from any single source that handles California workers’ compensation matters in the course of any consecutive twelve months.
Who are considered sources from which medical evaluators must not accept gifts exceeding $360?
Sources include but are not limited to one or more attorneys physicians employers claims administrators medical or health care or insurance or utilization review business entities.
What is the significance of the prohibition against accepting gifts by medical evaluators?
The prohibition against accepting gifts is significant to ensure that the evaluator remains impartial and that their evaluation report is not influenced by any external gifts or financial incentives.
What happens if a physician violates the gift acceptance rule as an Agreed Medical Evaluator in California workers’ compensation matters?
If a physician violates the gift acceptance rule it may result in disciplinary action by relevant regulatory or professional bodies and could undermine the validity of their evaluations.
Can an evaluator waive their conflict of interest?
Yes but any dispute over waiver of an evaluator’s conflict shall be determined by a Workers’ Compensation Administrative Law Judge.
What is the definition of income earned from a Medical Provider Network (MPN) according to Labor Code sections 4616 et seq?
Income earned from a Medical Provider Network (MPN) refers to the earnings received by medical providers for services rendered within the network defined under Labor Code sections 4616 et seq. This includes the amounts earned for treating injured workers as part of a fee schedule established by the MPN.
What types of income are excluded from the earnings of a treating physician as defined in Labor Code sections 4600.3 et seq?
Income earned as a treating physician that is considered unreasonable or inappropriate is excluded. This also applies to income from Health Care Organizations as defined in Labor Code sections 4600.3 et seq.
What is the definition of a Preferred Provider Organization (PPO) or Managed Care Organization (MCO) according to Health and Safety Code sections 1340 et seq?
A Preferred Provider Organization (PPO) or Managed Care Organization (MCO) is defined under Health and Safety Code sections 1340 et seq as an organization that provides or arranges for medical services in exchange for payment on a fee-for-service pre-paid or a combination of both.
Can a medical provider receive income for services performed as a reviewing physician or medical director?
No reasonable and appropriate income paid for services performed as a reviewing physician or medical director pursuant to Labor Code section 4610 is considered excluded from the definition of earnings.
What payments are classified as ‘Gifts’ under the definition provided?
Under the definition provided ‘Gift’ means any payment made where the receiver does not provide consideration of equal or greater value. This includes rebates or discounts unless they are part of the regular course of business to the public and loans forgiveness or other valuable items.
What is considered a ‘rebate’ in the context of gifts?
A rebate is considered a discount in the price of any valuable item unless this discount is provided as part of the regular course of business to all members of the public.
What are some of the exclusions for reasonable and appropriate income in the context of a treating physician?
Exclusions include income earned from services performed as a reviewing physician medical director Agreed Medical Evaluator or Qualified Medical Evaluator as well as any income deemed unreasonable or inappropriate.
What is the significance of Labor Code section 4610 regarding payments to medical providers?
Labor Code section 4610 outlines the parameters when medical providers can expect reasonable payment for services and states which types of income are excluded from this definition. It specifically impacts the role of reviewing physicians and medical directors.
Provide an example of a situation that would qualify as a ‘Gift’ under these definitions.
An example would be a medical provider receiving a payment from a pharmaceutical company for services rendered that significantly exceeds the norm - without providing equivalent value in return. As such the payment may be classified as a ‘Gift’.
What other terminology is important to understand in the context of Medical Provider Networks and Health Care Organizations?
It’s important to understand terms like ‘treating physician’ ‘Agreed Medical Evaluator’ ‘Qualified Medical Evaluator’ ‘reviewing physician’ ‘medical director’ and ‘reasonable and appropriate income’ as they relate to fee structures and earned income in the context of workers’ compensation and managed care.
What is the significance of market value in excess of 360 in the aggregate?
It indicates a threshold in which certain financial activities may need to be reported or are subject to regulation.
What must a person prove if they claim that a payment or rebate is not a gift due to consideration received?
The person must prove that the consideration received is of equal or greater value than the payment rebate discount loan or forgiveness.
What are the potential consequences for a Qualified Medical Evaluator who violates the regulation regarding gifts and benefits?
They shall be subject to disciplinary action as outlined in section 60 et seq of the regulations.
