5. QME Availability and Reports 1 Flashcards
What is the definition of medical-legal expense according to QME Availability and Reports disciplinary 4620?
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.
What is the purpose of medical-legal expenses?
The purpose of medical-legal expenses is to prove or disprove a contested claim.
What constitutes a contested claim in the context of the employer-employee relationship regarding industrial injury?
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.
Who may incur medical-legal expenses?
Medical-legal expenses can be incurred by or on behalf of any party involved the administrative director or the board.
What specific types of expenses are included under medical-legal expenses?
Included expenses are X-rays laboratory fees other diagnostic tests medical reports medical records medical testimony and interpreter’s fees by a certified interpreter.
What is the significance of a reasonable period in the context of an employer’s liability acceptance for benefits?
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.
What legal articles reference interpreter’s fees in the context of medical-legal expenses?
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.
Why might an employer reject liability for a claimed benefit?
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.
What is the time frame for an employer to contest a claim according to the provided text?
The employer must decide whether to contest the claim within the specified time period.
What happens if the employer fails to respond to a demand for payment of benefits?
The employer’s failure to respond occurs after the expiration of any time period fixed by statute for the payment of indemnity.
What do costs associated with medical evaluations diagnostic tests and interpreters constitute?
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.
What is the statute that defines the requirements for a medical report in California?
The requirements for a medical report are defined by the California Labor Code - LAB 4628.
When does a medical report qualify as a medical-legal expense?
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.
What entitlement does an injured employee have if they cannot effectively communicate with a physician during a medical examination?
The injured employee is entitled to the services of a qualified interpreter during the medical examination.
What language requirement affects an injured employee’s ability to communicate with an examining physician?
If the injured employee cannot proficiently speak or understand the English language it affects their ability to communicate effectively.
What is the purpose of the interpreter during the medical examination for an injured employee?
The purpose of the interpreter is to facilitate effective communication between the injured employee and the examining physician.
What is the significance of proving or disproving a medical fact in terms of adjudication of an employee’s claim for benefits?
Proving or disproving a medical fact is essential for the adjudication process of the employee’s claim for benefits.
As of what date is the California Code Labor Code - LAB 4628 current?
The California Code Labor Code - LAB 4628 is current as of January 01 2023.
Who pays for interpreter services for injured employees?
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.
Under what circumstances is an employer not required to pay for interpreter services?
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.
What are the restrictions placed on individuals who can examine an injured employee or participate in the preparation of the medical-legal report?
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.
What are some functions that must not be performed by anyone other than the signing physician regarding the medical-legal report?
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.
What should an employer do if they do not wish to pay for a provisional interpreter?
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.
What is the purpose of the fee schedule related to interpreter services?
The fee schedule adopted by the administrative director outlines the costs that the employer or insurance carrier will pay for the interpreter services.
What does Section 5811 pertain to?
Section 5811 pertains to the adoption of a fee schedule for interpreter services in cases involving injured employees.
What is a ‘medical-legal report’?
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.
What functionality can a nurse perform in the context of the medical-legal report?
A nurse may perform routine functions such as measuring blood pressure but cannot take medical history or summarize prior medical information for the report.
What is the implication of Section 11435.40 of the Government Code in relation to interpreter services?
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.
What happens if an injured worker requires interpreting services in a non-designated language?
In that case the employer is required to pay for the services of an interpreter even if that interpreter is provisionally certified.
What is meant by ‘provisionally certified’ in the context of interpreters?
‘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.
What should happen if a non-physician conducts medical functions related to an injured employee’s report?
Such actions are restricted; only physicians or nurses performing routine tasks may engage with the preparation of the medical-legal report.
Why is the consent of an employer important regarding the selection of an interpreter?
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.
What information must the medical report disclose regarding the evaluation’s date and location?
The report must disclose the date when and the location where the evaluation was performed.
Who must sign the medical report and what is their relationship to the evaluation?
The report must be signed by the physician or physicians who actually performed the evaluation.
What guidelines must the evaluation comply with according to the report?
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.
What personnel information must be included in the report?
The report must disclose the name and qualifications of each person who performed any services in connection with the report including diagnostic studies.
If the initial outline of a patient’s history is not done by the physician what is the physician’s responsibility?
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.
Is there a limitation on charges that can be made in connection with the evaluation?
Yes no amount may be charged in excess of the permissible fees as determined by relevant regulations.
What does Section 139.2 and Section 5307.6 pertain to in medical evaluations?
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.
How important is it for a physician to review prior medical records before conducting an evaluation?
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.
What constitutes compliance in the context of medical evaluation?
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.
What should a physician do if they find discrepancies during their review of excerpts of the patient’s medical history?
The physician should make additional inquiries and perform examinations as necessary to clarify discrepancies and ensure all relevant medical issues are adequately addressed.
What are the direct charges that can be billed for a physician’s professional services?
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.
What happens if a physician fails to comply with the requirements for reporting medical-legal expenses?
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.
What is the civil penalty for knowing failure to comply with the reporting requirements?
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.
Who assesses the civil penalties for failing to comply with reporting requirements?
Civil penalties are assessed by a workers’ compensation judge or the appeals board.
Where are all civil penalties collected under the reporting requirements deposited?
All civil penalties collected under this section shall be deposited in the Workers’ Compensation Administration Revolving Fund.
What consequences face a physician who is assessed a civil penalty?
The input provided did not specify the exact consequences that face a physician who is assessed a civil penalty under this section.
What types of expenses are included in the reasonable costs associated with a physician’s report?
Reasonable costs associated with a physician’s report include laboratory examinations diagnostic studies other medical tests and clerical expenses necessary to produce the report.
Are overhead expenses included in the direct charges for a physician’s professional services?
Yes direct charges for a physician’s professional services shall include reasonable overhead expenses.
What actions can lead to a physician being terminated suspended or placed on probation as a qualified medical evaluator?
Actions leading to termination suspension or probation include failure to comply with the requirements outlined in subdivisions k and l of Section 139.2.
What are the consequences of failing to comply with the requirements of Section 139.2 for a physician?
Failing to comply can result in the physician being held in contempt by the judicial powers vested in the appeals board.
Who must specify the amount paid for medical-legal evaluations diagnostic procedures or services?
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.
What is the exception stated regarding the billing for procedures or services in the context of Section 5307.1?
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.
What must be included in the medical report by the physician signing it?
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.
What is the significance of the declaration under penalty of perjury in the medical report?
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.
What is the declaration made by the physician regarding the information provided?
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.
What must the physician include in the declaration aside from the statement of truth?
The declaration must be dated and signed by the reporting physician and must indicate the county in which it was signed.
What document must a physician provide upon request by a party?
The physician must provide a curriculum vitae (CV) upon request by a party.
What specific information must be included by the physician in the curriculum vitae?
The curriculum vitae must include a statement concerning the percent of the physician’s total practice time that is annually devoted to medical treatment.
How are QME panels selected according to the document?
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.
What role does the Medical Director play in the selection of QME panels?
The Medical Director is responsible for excluding certain individuals from the panel based on established criteria.
