3 Rules (2-3 hrs.) Flashcards
Everyone has them, these are for the QME
What is the rule of exclusive remedy?
Worker cannot pursue other civil action, even if employer was negligent, unless the employer is uninsured for work comp
By what percentage is the employee’s compensation increased if an injury resulted from serious and willful misconduct of an employer?
50%
What are the 7 exceptions to claiming something as a work related injury?
- if etoh/drugs were used; 2. intentionally self inflicted harm 3. suicide 4. injury from an altercation in which the employee is an aggressor 5. injuries from a crime 6. injuries during off duty recreational activities 7. psych injuries claimed after termination
For injuries that result from serious and willful misconduct of an injured employee, benefits are reduced by ____ unless_____
50%; unless death or permanent disability of >70%, age <16, or injury resulted from failure of employer to comply with health/safety laws
When first aid is administered, what reports should be filed
Doctors first report (employers first report is not required)
Employers have an obligation to authorize up to $________ within 1 working day after a claim is filed
$10,000
Which 6 components should be included in an occupational history
- all jobs worker has held; 2. length of employment; 3. specific job duties; 4. how much time was spent on each task 5. occupational hazard exposures; 6. what protective equipment was used
What are the 7 exceptions to claiming something as a work related injury? (logical, just think about it)
- if etoh/drugs were used; 2. intentionally self inflicted harm 3. suicide 4. injury from an altercation in which the employee is an aggressor 5. injuries from a crime 6. injuries during off duty recreational activities 7. psych injuries claimed after termination
In which conditions in firefighters, forestry officers, peace officers and correctional employees is the burden of proof on the employer?
hernias, pneumonia, TB, heart dz, cancer
Principle of “taking employees as you find them”
The employer cannot avoid liability for an occupational injury by claiming the injury would not have happened if the worker had been in a different physical or emotional condition before the accident.
When is a psych injury compensable? “burden of proof”
employment events contribute >50% to injury (or >35% if a violent act was witnessed example Bank Robbery)
When are psych injuries not compensable?
if worker has worked there <6 months in total, if claim is due to personnel matters, or if claim is filed after notice of termination (except in extreme cases)
After how many visits can a chiropractor no longer be the treating physician
24
For injuries occurring after which date are the AMA guides used to evaluate disability?
1/1/2005
What event generally triggers a QME evaluation under LC 4061
permanent disability dispute after the PTP claims worker is P&S and termination of temporary disability
What is a QME evaluation under LC 4060
Helping to determining the compensability of a claim after claim form is filed but before the body part has been accepted by the claims administrator
What disputes fall under LC 4062?
- is worker temporarily disabled? 2. does worker need work restrictions? 3. is there a new/further disability after judicial determination of permanent disability as a result of injury deterioration 4. whether a new body part added to the claim
Since when has disputes over what medical treatment not done by QMEs
since 7/1/2013–now resolved by IMR process if UR is denied
What is the difference between QME forms 105 and 106?
105–unrepresented workers; 106–represented workers
who gets the first opportunity to request a QME panel?
injured worker
Can a worker get a second med-legal evaluation if they later become represented by an attorney?
No
QME evaluations are only available for represented workers for DOI after______?
1/1/2005
Can an evaluator cancel an appointment for lack of medical records?
No (unless psych)
The April 1997 Permanent Disability Rating Schedule (PDRS) can be used for a DOI prior to_____?
1/1/2005
Now we use the AMA Gides 5th Ed for Whole Person Impairment %
How can an unrepresented worker ask for a factual correction to a QME report?
File form QME 37, asking the QME to correct facts; The QME has 10 days to do so.
What is the process for sending records to a QME?
records must first be served to the opposing party 20 days before it is provided to the QME; if the opposing party objects to sending non-medical records within 10 days of its receipt, it will not be provided to the QME
Which records are prohibited from being sent to a QME?
1, any prior report that has been rejected as untimely; 2. an MD report that talks about impairment/disability that is not by a PTP, secondary physician, or QME (unless judge rules it admissible) 3. Any record that has been stricken by a judge
How much $ does a worker receive for total disability?
weekly amount that was determined for temporary disability for life
If the Injured Worker can NOT return to their job, they are a QIW (Quilified Injured Worker) and get $ to retrain called: Supplemental Job Displacement Benefits (SJDB), PAY OUT AMOUNTS
For injuries before 1-1-13 the voucher amount ranges from $4000 to $10,000 depending upon the permanent disability rating
For dates of injury on/after 1-1-13 the voucher will be $6000 across the board, regardless of the permanent disability rating
The voucher will be due 60 days after a treating doctor, AME or QME declares the injured worker permanent and stationary, reports what the worker’s work capabilities are
and the employer does not offer the worker a job
If offered, the job must pay no less than 85% of the worker’s earnings at the time of the injury, and be expected to last at least 12 months
The SJDB voucher can be used for?
Training at a California public school, or other approved provider listed by the state
To pay for licensing or certification and testing fees
Purchase tools required by a training course
Up to $1000 to purchase a computer and/or $500 in miscellaneous expenses
Up to $600 for the services of a licensed placement agency or vocational counselor
What are the voucher amounts for supplemental job displacement benefits?
PDRS<15% $4000; 15-25%: $6000 26-49%: $8000; 50-99%: $10,000
How much $ does a worker receive for partial disability
weekly payments for a number week weeks determined by employer’s disability rating and a small pension for life if >70% disability
Who qualifies for SJDB. Vouchers? What amount?
Employees injured on or after 1/1/04 whose employers do not provide alternative work; amount is $6000 if injured on or after 1/1/2013 and varies based on disability level for 1/1/04-12/31/12
How much voucher $ can be used for vocational and return to work counseling?
up to 10%
Can a physician determine disability?
No. QME determines impairment rating
When does the physician calculate the disability rating?
Never (the physician provides an impairment rating only and apportionment)
What 2 additional things go with a PR-4 report?
- Description of any permanent impairment; 2. RTW and voucher report for any permanent partial disability
What is one of the best treatments for delayed recovery and chronic pain?
CBT Cognitive Behavioral Therapy
What are the only reports a judge can use to make a permanent disability award for an unrepresented worker?
QME, AME and PTP reports
Are AMEs regulated by the DWC?
No
What can happen to a QME if they don’t report people who helped put together the report?
Termination as a QME
What must a QME inform an unrepresented worker of at the beginning of the evaluation?
worker’s rights to ask questions regarding the evaluation process and about the evaluator’s background
When can chronic pain be considered ratable?
- if the symptoms/exam match a known medical condition 2. if the presentation is typical of the diagnosed condition and 3. if the diagnosed condition is widely accepted by a pathophysiologic basis
Note: QME can add upto 3% WPI for Pain
when pain is considered unratable, what does that really mean?
QME is unable to determine how the activity restrictions are linked to disease or injury
If rating a pain related impairment, what 2 things must a physician do to rate?
- increase WPI by up to 3% and classify the impairment into mild, moderate, moderately severe or severe
What is the rule about modified/alternative work that an employer provides after a worker is P&S for DOI btw 1/1/05 and 12/31/12
If an employer with > 50 employees fails to provide alternative work within 60 days of an employee becoming P&S, disability payments increase by 15%; if they are able to provide it, payments decrease by 15%
An IW having had 3 similar jobs at 3 different employers, but realized she had a problem/injury of a cumulative nature while working for the most recent employer would place liability for any resultant disability/impairment on:
A. The most recent employer with WC insurance
B. The employer where the problem/injury first began
Which of the following specialties/disciplines are prohibited from writing a medical legal report in a case where impairment/disability is being disputed:
Acupuncture - Can complete the entire report except the impairment rating
Cases involving work acquired HIV/AIDS involve confidentiality for the IW that involves:
Normal medical confidentiality laws
The maintenance of a fictitious name file maintained by a WCJ
A QME or AME must address all disputed issues in a claim with the exception of…?
Medical treatment disputes are now done by an IMR
Which of the following can a QME or AME not do with regard to the IW being evaluated?
QME can NOT provide treatment on that day, unless it is a medical emergency
If impairment for a given condition is not listed in the AMA Guide (5th Ed.), the evaluator may use an impairment value for a listed condition that more accurately characterizes the IW’s impairment, as long as it:
Is contained within a chapter of the AMA Guide 5th Edition
(Almaraz Guzman Rule)
An Information & Assistance Officer can talk to a represented IW, an unrepresented IW and anyone else.
True
Secondary erectile dysfunction, sleep disorders and/or psych disorders that are a
compensable consequence of the primary injury for 1.1.13 injuries and forward are
Treatable under the claim but not ratable with regard to disability/impairment
Ratable if catastrophic in nature
When measuring extremity joint ranges of motion (ROM) in cases made permanent & stationary prior to 2005, which standard normal values are used?
Packard Thurber’s ‘Estimated Average Normals’ 1960
Can an IW tape record the QME examination?
Yes
When evaluating an injured extremity in a 2010 case, the evaluator must do which of the following?
Compare findings to normal values in the AMA Guide (5th Ed.)
Compare findings to the opposite, un-injured extremity
Does a QME need authorization to refer out an IW for medically reasonable and necessary consultations and/or diagnostic testing?
Yes
If any IW self-procures an evaluation from a doctor who is not the PTP or the QME, which of the following is true?
The PTP or the QME must issue a supplemental report commenting on the self-procured report
The self-procured report is inadmissible
Temporary disability benefits normally cannot be paid for longer than 2 years (104 weeks), unless the injury involves which of the following?
Severe burns
Chronic lung disease
Amputation
The time that the injured worker spends with an interpreter can be calculated as the doctor’s face to face time with the patient when?
No. The doctor is face to face with the injured worker interacting
Medical research involves investigating medical issues by reading medical and scientific journals and texts. It does not include reading or reviewing which of the following?
AMA Guides for the Evaluation of Permanent Impairment
Treatment guidelines (ACOEM – MTUS)
Labor Codes
California Code of Regulations
The QME/AME is permitted to talk to whom?
PTP
When the PTP writes a permanent and stationary (P&S) report it is not considered a medical-legal report, unless
The claim is contested or disputed
‘Physician’s office’ means a bona fide office facility which is identified by a street address and any other more specific designation such as a suite or room number and which contains the usual and customary equipment for the evaluation and treatment appropriate to the physician’s medical specialty or practice. Which does not apply?
Post Office Box
Parking lot
Home
Retail store
The injured worker may discontinue the evaluation based on good cause, including:
Discriminatory conduct toward the worker based on race or sex
Discriminatory conduct toward the worker based on religion or sexual preference
Requests for the worker to submit to unnecessary examination or procedure
Abusive, hostile or rude behavior toward the worker that demonstrates bias
Benefits available to the injured worker are:
Medical treatment
Temporary disability payments
Permanent disability payments
Vocational rehabilitation services Death benefits
In cases involving physical injury for 1.1.13 dates of injury and forward, injured workers will not be able to collect additional permanent disability for sleep disorders, sexual dysfunction, or psych injuries that did not directly result from those injuries. QME/AMEs and PTPs will not be able to comment on permanent disability add-ons for which conditions, however, can discuss need for treatment:
Sleep disorders
Sexual dysfunction
Psychological issues, unless the physical injury is ‘catastrophic,’ or where the injured worker was the victim of a violent act or a witness to a violent act/crime
In the event that no records are received by the QME/AME to prepare and issue a medical-legal report, what do you do?
The QME report must be served within 30 calendar days with or without records
The QME can contact the treating physician to obtain records
The QME should issue a supplemental report when the records are received
When an injured worker does not speak or understand the English language and an interpreter is used in a medical-legal evaluation. What type?
Only a Certified interpreter. Include name and certification number in the report
No AME or QME shall accept gifts that have a total fair market value in the aggregate of _____ for more, from any single source that handles California workers’ compensation matters, in the course of any consecutive 12 months.
$360
The AMA 5th Ed. Guides consider both anatomic and functional loss in evaluating impairment.
Anatomic loss refers to damage to an organ system or body structure
Functional loss refers to a change in function for the organ or body system
Impairment criteria contained in the Guides provides a standardized method for physicians to use to determine medical impairment
The impairment criteria in the Guides were developed from scientific evidence and from consensus of chapter authors or of medical specialty societies
For dates of injury before 2005, Subjective Factors of Disability are used to determine frequency of symptoms/complaints. Define Occasional, Intermittent, Frequent & Constant based on %.
Occasional pain occurs approximately 25% of the time Intermittent pain occurs approximately 50% of the time
Frequent pain occurs approximately 75% of the time
Constant pain occurs approximately 90 to 100% of the time
For dates of injury before 2005, Subjective Factors of Disability are used to determine intensity of symptoms/complaints. Define Mild, Slight, Moderate & Severe Pain.
Minimal (or mild) pain would constitute an annoyance, but would cause no handicap in the performance of a particular activity and is non-ratable.
Slight pain can be tolerated but would cause some handicap in the performance of the activity precipitating the pain.
Moderate pain can be tolerated, but would cause a marked handicap in the performance of the activity precipitating the pain.
Severe pain, would preclude the activity precipitating the pain.
Permanent Disability reports for musculoskeletal injuries for dates of injury before 2005 take into consideration for rating purposes, which of the following?
Subjective Factors of Disability
Objective Factors of Disability
Work Preclusions or Restrictions
If employer doesn’t provide a return to work DATE 60 days after the RTW and voucher report, then what kicks in?
Supplemental Job Displacement Benefit (SJBD).
6K. 1K towards computer. The rest is resume, job search, exam fees etc.
3 reasons for ineligibility for IMR:
- didn’t submit IMR application within 30 days of adverse UR determination
- didn’t sign IMR application
- dispute reg. liability
If the employer doesn’t have an MPN & didn’t provide a new PTP within 30 days, then IW can chose their…
personal chiro or acupuncturist if they are pre-designated. . Otherwise boss has control over 1st 30 days of who the PTP is.
Temporary disability is not paid for IW for …. (hrs/days) unless they are hospitalized/miss work for more than 14 days
3 days
Generally, an employer must deny a claim within 90 days to avoid a presumption that it’s compensable.
(TRUE/FALSE)
TRUE. Labor Code 5402(b)(1) states, “If liability is not rejected within 90 days after the date the claim form is filed under Section 5401, the injury shall be presumed compensable under this division.”
