5. QME Availability and Reports 1

Question 1

What is the definition of medical-legal expense according to QME Availability and Reports disciplinary 4620?

Answer 1

A medical-legal expense means any costs and expenses incurred by or on behalf of any party the administrative director or the board. These expenses may include X-rays laboratory fees other diagnostic tests medical reports medical records medical testimony and interpreter’s fees by a certified interpreter as needed.

Question 2

What is the purpose of medical-legal expenses?

Answer 2

The purpose of medical-legal expenses is to prove or disprove a contested claim.

Question 3

What constitutes a contested claim in the context of the employer-employee relationship regarding industrial injury?

Answer 3

A contested claim exists when the employer knows or reasonably should know that the employee is claiming entitlement to a benefit arising out of a claimed industrial injury and either (1) the employer rejects liability for a claimed benefit or (2) the employer fails to accept liability for benefits after the expiration of a reasonable period.

Question 4

Who may incur medical-legal expenses?

Answer 4

Medical-legal expenses can be incurred by or on behalf of any party involved the administrative director or the board.

Question 5

What specific types of expenses are included under medical-legal expenses?

Answer 5

Included expenses are X-rays laboratory fees other diagnostic tests medical reports medical records medical testimony and interpreter’s fees by a certified interpreter.

Question 6

What is the significance of a reasonable period in the context of an employer’s liability acceptance for benefits?

Answer 6

The significance of a reasonable period is that if an employer fails to accept liability for benefits after this period it can lead to a contested claim signifying a dispute over entitlement to benefits.

Question 7

What legal articles reference interpreter’s fees in the context of medical-legal expenses?

Answer 7

Interpreter’s fees are referenced in Article 8 starting with Section 11435.05 of Chapter 4.5 of Part 1 of Division 3 of Title 2 or Section 68566 of the Government Code.

Question 8

Why might an employer reject liability for a claimed benefit?

Answer 8

An employer might reject liability for a claimed benefit if they believe the claim is not valid or if they dispute the circumstance surrounding the claimed industrial injury.

Question 9

What is the time frame for an employer to contest a claim according to the provided text?

Answer 9

The employer must decide whether to contest the claim within the specified time period.

Question 10

What happens if the employer fails to respond to a demand for payment of benefits?

Answer 10

The employer’s failure to respond occurs after the expiration of any time period fixed by statute for the payment of indemnity.

Question 11

What do costs associated with medical evaluations diagnostic tests and interpreters constitute?

Answer 11

These costs do not constitute medical-legal expenses unless the medical report can prove or disprove a disputed medical fact essential to adjudicating the employee’s claim for benefits.

Question 12

What is the statute that defines the requirements for a medical report in California?

Answer 12

The requirements for a medical report are defined by the California Labor Code - LAB 4628.

Question 13

When does a medical report qualify as a medical-legal expense?

Answer 13

A medical report qualifies as a medical-legal expense if it can prove or disprove a disputed medical fact that is essential to the adjudication of the employee’s claim for benefits.

Question 14

What entitlement does an injured employee have if they cannot effectively communicate with a physician during a medical examination?

Answer 14

The injured employee is entitled to the services of a qualified interpreter during the medical examination.

Question 15

What language requirement affects an injured employee’s ability to communicate with an examining physician?

Answer 15

If the injured employee cannot proficiently speak or understand the English language it affects their ability to communicate effectively.

Question 16

What is the purpose of the interpreter during the medical examination for an injured employee?

Answer 16

The purpose of the interpreter is to facilitate effective communication between the injured employee and the examining physician.

Question 17

What is the significance of proving or disproving a medical fact in terms of adjudication of an employee’s claim for benefits?

Answer 17

Proving or disproving a medical fact is essential for the adjudication process of the employee’s claim for benefits.

Question 18

As of what date is the California Code Labor Code - LAB 4628 current?

Answer 18

The California Code Labor Code - LAB 4628 is current as of January 01 2023.

Question 19

Who pays for interpreter services for injured employees?

Answer 19

The employer or insurance carrier shall pay the costs of interpreter services as set forth in the fee schedule adopted by the administrative director pursuant to Section 5811.

Question 20

Under what circumstances is an employer not required to pay for interpreter services?

Answer 20

An employer is not required to pay for the services of an interpreter who is provisionally certified unless the employer consents in advance to the selection of the interpreter or if the injured worker requires interpreting service in a language other than those designated pursuant to Section 11435.40 of the Government Code.

Question 21

What are the restrictions placed on individuals who can examine an injured employee or participate in the preparation of the medical-legal report?

Answer 21

Except as provided in subdivision c only the physician who signs the medical-legal report or a nurse performing routine functions (like taking blood pressure) can examine the injured employee or participate in the nonclerical preparation of the report.

Question 22

What are some functions that must not be performed by anyone other than the signing physician regarding the medical-legal report?

Answer 22

Functions such as taking a complete history and reviewing and summarizing prior medical history are restricted to the physician who signs the medical-legal report.

Question 23

What should an employer do if they do not wish to pay for a provisional interpreter?

Answer 23

The employer must consent in advance to the selection of the provisional interpreter or if the injured worker requires interpreting service in a language other than the designated languages.

Question 24

What is the purpose of the fee schedule related to interpreter services?

Answer 24

The fee schedule adopted by the administrative director outlines the costs that the employer or insurance carrier will pay for the interpreter services.

Question 25

What does Section 5811 pertain to?

Answer 25

Section 5811 pertains to the adoption of a fee schedule for interpreter services in cases involving injured employees.

Question 26

What is a 'medical-legal report'?

Answer 26

A medical-legal report is a documentation signed by a physician which outlines the findings after an examination of an injured employee used for legal and insurance purposes.

Question 27

What functionality can a nurse perform in the context of the medical-legal report?

Answer 27

A nurse may perform routine functions such as measuring blood pressure but cannot take medical history or summarize prior medical information for the report.

Question 28

What is the implication of Section 11435.40 of the Government Code in relation to interpreter services?

Answer 28

Section 11435.40 of the Government Code designates specific languages for which interpreting services are typically required impacting the employer's obligation to pay for interpreting services.

Question 29

What happens if an injured worker requires interpreting services in a non-designated language?

Answer 29

In that case the employer is required to pay for the services of an interpreter even if that interpreter is provisionally certified.

Question 30

What is meant by 'provisionally certified' in the context of interpreters?

Answer 30

'Provisionally certified' refers to interpreters who have not yet completed the full certification process but possess a certain level of proficiency and are permitted to provide interpreting services under specific conditions.

Question 31

What should happen if a non-physician conducts medical functions related to an injured employee's report?

Answer 31

Such actions are restricted; only physicians or nurses performing routine tasks may engage with the preparation of the medical-legal report.

Question 32

Why is the consent of an employer important regarding the selection of an interpreter?

Answer 32

The consent is crucial because it ensures the employer agrees to the professional qualifications and capabilities of the interpreter to maintain the integrity and accuracy of the interpreted communication.

Question 33

What information must the medical report disclose regarding the evaluation's date and location?

Answer 33

The report must disclose the date when and the location where the evaluation was performed.

Question 34

Who must sign the medical report and what is their relationship to the evaluation?

Answer 34

The report must be signed by the physician or physicians who actually performed the evaluation.

Question 35

What guidelines must the evaluation comply with according to the report?

Answer 35

The evaluation must comply with the guidelines established by the administrative director pursuant to paragraph 5 of subdivision j of Section 139.2 or Section 5307.6.

Question 36

What personnel information must be included in the report?

Answer 36

The report must disclose the name and qualifications of each person who performed any services in connection with the report including diagnostic studies.

Question 37

If the initial outline of a patient's history is not done by the physician what is the physician's responsibility?

Answer 37

If the initial outline of a patient's history or excerpting of prior medical records is not done by the physician the physician shall review the excerpts and the entire outline and make additional inquiries and examinations as necessary to identify and determine the relevant medical issues.

Question 38

Is there a limitation on charges that can be made in connection with the evaluation?

Answer 38

Yes no amount may be charged in excess of the permissible fees as determined by relevant regulations.

Question 39

What does Section 139.2 and Section 5307.6 pertain to in medical evaluations?

Answer 39

Section 139.2 and Section 5307.6 pertain to guidelines and regulations that must be followed during medical evaluations to ensure compliance and proper documentation.

Question 40

How important is it for a physician to review prior medical records before conducting an evaluation?

Answer 40

It is crucial for a physician to review prior medical records before conducting an evaluation as it helps identify and determine relevant medical issues that could impact patient care.

Question 41

What constitutes compliance in the context of medical evaluation?

Answer 41

Compliance in the context of medical evaluation means that the evaluation was performed according to the established guidelines with appropriate documentation of time spent location and personnel involved.

Question 42

What should a physician do if they find discrepancies during their review of excerpts of the patient's medical history?

Answer 42

The physician should make additional inquiries and perform examinations as necessary to clarify discrepancies and ensure all relevant medical issues are adequately addressed.

Question 43

What are the direct charges that can be billed for a physician's professional services?

Answer 43

The direct charges for a physician's professional services include the reasonable costs of laboratory examinations diagnostic studies other medical tests clerical expenses necessary for producing reports and reasonable overhead expenses.

Question 44

What happens if a physician fails to comply with the requirements for reporting medical-legal expenses?

Answer 44

Failure to comply with the requirements for reporting makes the report inadmissible as evidence and eliminates any liability for payment of any medical-legal expenses incurred in connection with the report.

Question 45

What is the civil penalty for knowing failure to comply with the reporting requirements?

Answer 45

Knowing failure to comply with the requirements shall subject the physician to a civil penalty of up to one thousand dollars ($1000) for each violation.

Question 46

Who assesses the civil penalties for failing to comply with reporting requirements?

Answer 46

Civil penalties are assessed by a workers' compensation judge or the appeals board.

Question 47

Where are all civil penalties collected under the reporting requirements deposited?

Answer 47

All civil penalties collected under this section shall be deposited in the Workers' Compensation Administration Revolving Fund.

Question 48

What consequences face a physician who is assessed a civil penalty?

Answer 48

The input provided did not specify the exact consequences that face a physician who is assessed a civil penalty under this section.

Question 49

What types of expenses are included in the reasonable costs associated with a physician’s report?

Answer 49

Reasonable costs associated with a physician's report include laboratory examinations diagnostic studies other medical tests and clerical expenses necessary to produce the report.

Question 50

Are overhead expenses included in the direct charges for a physician's professional services?

Answer 50

Yes direct charges for a physician's professional services shall include reasonable overhead expenses.

Question 51

What actions can lead to a physician being terminated suspended or placed on probation as a qualified medical evaluator?

Answer 51

Actions leading to termination suspension or probation include failure to comply with the requirements outlined in subdivisions k and l of Section 139.2.

Question 52

What are the consequences of failing to comply with the requirements of Section 139.2 for a physician?

Answer 52

Failing to comply can result in the physician being held in contempt by the judicial powers vested in the appeals board.

Question 53

Who must specify the amount paid for medical-legal evaluations diagnostic procedures or services?

Answer 53

Any person billing for these evaluations procedures or services must specify the amount paid or to be paid to those performing them as long as they are not employed by the reporting physician or a medical corporation owned by them.

Question 54

What is the exception stated regarding the billing for procedures or services in the context of Section 5307.1?

Answer 54

The exception states that the requirement to specify payment does not apply to any procedure or service defined or valued pursuant to Section 5307.1.

Question 55

What must be included in the medical report by the physician signing it?

Answer 55

The report must contain a declaration by the physician under penalty of perjury stating that the information in the report and its attachments is true.

Question 56

What is the significance of the declaration under penalty of perjury in the medical report?

Answer 56

The declaration under penalty of perjury signifies that the physician is legally attesting to the accuracy and truthfulness of the information contained in the report and its attachments.

Question 57

What is the declaration made by the physician regarding the information provided?

Answer 57

The declaration states that the information is true and correct to the best of the physician's knowledge and belief except for information indicated as received from others. The physician declares under penalty of perjury that the information accurately describes what was provided to them and believes it to be true.

Question 58

What must the physician include in the declaration aside from the statement of truth?

Answer 58

The declaration must be dated and signed by the reporting physician and must indicate the county in which it was signed.

Question 59

What document must a physician provide upon request by a party?

Answer 59

The physician must provide a curriculum vitae (CV) upon request by a party.

Question 60

What specific information must be included by the physician in the curriculum vitae?

Answer 60

The curriculum vitae must include a statement concerning the percent of the physician's total practice time that is annually devoted to medical treatment.

Question 61

How are QME panels selected according to the document?

Answer 61

QME panels are selected randomly from the appropriate specialty identified by the party who has the legal right to designate the specialty with consideration given to the proximity of the QME's medical office to the employee's residence.

Question 62

What role does the Medical Director play in the selection of QME panels?

Answer 62

The Medical Director is responsible for excluding certain individuals from the panel based on established criteria.