5. QME Availability and Reports 2 Flashcards
What is the importance of declaring the information under penalty of perjury?
Declaring the information under penalty of perjury emphasizes the legal consequences of providing false information thus ensuring the integrity of the information submitted.
Why is it important for the physician’s CV to include practice time devoted to medical treatment?
Including the percentage of practice time devoted to medical treatment helps to provide context regarding the physician’s experience and expertise in the relevant medical field which can affect their credibility as a QME.
What should any QME inform the Medical Director of if they are unavailable?
Any QME who is unavailable must inform the Medical Director pursuant to section 33 of Title 8 of the California Code of Regulations.
Can a physician who has treated an employee as a primary or secondary physician perform a QME evaluation on that employee?
No a physician who has served as a primary treating physician or secondary physician and has provided treatment to the employee for the disputed injury in accordance with section 9785 of Title 8 of the California Code of Regulations shall not perform a QME evaluation on that employee.
What should a physician do if contacted to perform a QME evaluation but their name is on the QME panel?
If a physician’s name appears on a QME panel and they are contacted by a party to perform the evaluation they shall disqualify themselves.
What can either party do if they want a replacement QME due to disqualification?
Either party may request a replacement QME pursuant to section 31.5 of Title 8 of the California Code of Regulations.
What is required to issue a QME panel in a selected specialty?
To issue a panel in a selected specialty there must be at least five active QMEs in that specialty at the time the panel selection is requested.
What happens if there are fewer than five active QMEs in a requested specialty when a panel selection is requested?
If there are less than five active QMEs in the requested specialty the Medical Director shall contact the appropriate parties (not specified in the available text but typically relevant regulatory offices or organizations) for further action.
What party holds the legal right to designate the specialty for an alternate specialty selection?
The party who holds the legal right to designate the specialty for an alternate specialty selection is specified in the relevant section but is not explicitly mentioned in the provided text.
How are disputes regarding the validity of panel requests resolved in represented cases?
Disputes regarding the validity of panel requests shall be resolved by a Workers’ Compensation Administrative Law Judge.
What is the process for resolving disputes regarding the appropriateness of the specialty designated?
Disputes regarding the appropriateness of the specialty designated shall be resolved pursuant to section 31.5a10 of Title 8 of the California Code of Regulations.
Can either party appeal the Medical Director’s decision about the appropriateness of the specialty?
Yes either party may appeal the Medical Director’s decision as to the appropriateness of the specialty to a Workers’ Compensation Administrative Law Judge.
What happens if the Medical Director is unable to issue a QME panel within thirty (30) calendar days in a represented case?
If the Medical Director is unable to issue a QME panel in a represented case within thirty (30) calendar days of receiving the request either party may seek an order from a Workers’ Compensation Administrative Law Judge that a QME panel be issued.
What must every order from a Workers’ Compensation Administrative Law Judge specify regarding the QME panel?
Any such order shall specify the specialty of the QME panel or the party to be designated to select the specialty.
What is the timeframe for an unrepresented employee to select a QME after receiving the panel form?
The unrepresented employee has ten (10) days to select a QME from the panel list after being furnished with the form.
What must the unrepresented employee do after selecting a QME?
The unrepresented employee must contact the selected QME to schedule an appointment and inform the claims administrator of the QME selection and the appointment.
Are employers or their representatives allowed to discuss the selection of the QME with an unrepresented worker?
No neither the employer nor the claims administrator nor any other representative of the employer shall discuss the selection of the QME with an unrepresented worker who has the legal right to select the QME.
What happens if an unrepresented employee does not select a QME within ten days of the issuance of the QME panel?
If the unrepresented employee fails to select a QME or fails to schedule an appointment within ten (10) days the claims administrator may schedule an appointment with a panel QME as provided in Labor Code section 4062.1c and must notify the employee of the appointment.
What section of the Labor Code provides guidelines for the claims administrator’s actions if an unrepresented employee fails to select a QME?
Labor Code section 4062.1c.
When the employee is represented by an attorney what procedural changes apply regarding the selection of a QME?
The text does not provide information on the specific procedural changes when the employee is represented by an attorney but it implies that different protocols must be followed when an attorney is involved.
What happens after parties have completed the striking processes in Labor Code section 4062.2c?
After completing the striking processes described in Labor Code section 4062.2c the represented employee must schedule an appointment with the physician selected from the Qualified Medical Evaluator (QME) panel.
What is the timeframe for a represented employee to schedule an appointment with the selected QME?
The represented employee must schedule the appointment within ten (10) business days of the date a QME is selected from the panel.
What occurs if the represented employee does not schedule the appointment within the allocated timeframe?
If the represented employee fails to schedule the appointment within ten (10) business days the claims administrator or the administrator’s attorney may arrange the appointment and notify the employee and the employee’s attorney.
What can a party do if they cannot obtain an appointment with a selected QME within ninety days?
If a party with the legal right to schedule an appointment with a QME is unable to obtain an appointment within ninety (90) days of the request that party may waive the right to a replacement QME in order to accept an appointment no more than one-hundred twenty (120) days after the initial request.
What happens if the selected QME cannot schedule an evaluation within the one-hundred-twenty-day timeframe?
If the selected QME is unable to schedule the evaluation within one-hundred twenty (120) days of the initial appointment request either party may report the issue.
What is a QME in the context of Labor Code section 4062.2c?
A Qualified Medical Evaluator (QME) is a physician selected from a panel to evaluate an employee’s medical condition typically in the context of workers’ compensation claims.
What is the purpose of the striking process described in Labor Code section 4062.2c?
The striking process allows parties to remove certain evaluators from a list of QMEs to ensure an impartial and fair selection for a medical evaluation.
How long does a party have to wait after their initial request for an appointment before they can accept a scheduled appointment beyond the initial selection?
A party may accept a scheduled appointment no later than one-hundred twenty (120) days after the date of the party’s initial request for an appointment.
In what situation can a claims administrator arrange the appointment with a QME?
The claims administrator can arrange the appointment with a QME if the represented employee fails to schedule it within ten (10) business days post-selection.
What notification is required when a claims administrator arranges the QME appointment?
The claims administrator must notify both the employee and the employee’s attorney when arranging the appointment.
What happens if the initially selected Qualified Medical Evaluator (QME) is unavailable?
If the initially selected QME is unavailable the Medical Director shall issue a replacement pursuant to section 31.5 of Title 8 of the California Code of Regulations upon request. This is unless both parties agree in writing to waive the 120-day time limit for scheduling the initial or any subsequent evaluation.
What is the 120-day time limit related to in the context of a QME evaluation?
The 120-day time limit refers to the maximum time allowed for scheduling the initial QME evaluation or any subsequent evaluation which can be waived if both parties agree in writing.
To what evaluations does subdivision e of the regulations apply?
Subdivision e of the regulations applies to both requests for any Comprehensive Medical-Legal Evaluation by a QME and requests for Follow-Up Comprehensive Medical-Legal Evaluations by a QME.
What are the conditions under which a replacement QME might be requested?
A replacement QME may be requested under the following conditions: 1. A QME on the panel issued does not practice in the specialty requested by the party holding the legal right to request the panel. 2. A QME on the panel issued cannot schedule an examination.
What authority does the Medical Director have regarding QME selection?
The Medical Director has the authority to select a replacement QME or at their discretion replace the entire panel of QMEs. This selection is done at random upon request.
What is the procedure for requesting a replacement QME?
A replacement QME can be requested when any of the specified conditions occur and the Medical Director will select a new QME at random and provide it upon request.
What section of the California Code of Regulations addresses QME replacements?
Section 31.5 of Title 8 of the California Code of Regulations addresses QME replacements.
What types of evaluations are included in the terms of ‘Comprehensive Medical-Legal Evaluation’ and ‘Follow Up Comprehensive Medical-Legal Evaluations’?
Both ‘Comprehensive Medical-Legal Evaluation’ and ‘Follow Up Comprehensive Medical-Legal Evaluations’ refer to evaluations conducted by a Qualified Medical Evaluator for purposes related to legal claims including but not limited to workers’ compensation cases.
Can parties agree to extend the time for scheduling evaluations?
Yes both parties can agree in writing to waive the 120-day time limit for scheduling the initial or any subsequent evaluation.
What is the significance of having a QME with the appropriate specialty?
Having a QME with the appropriate specialty is crucial because it ensures that the evaluator has the relevant expertise and qualifications needed to provide an accurate assessment related to the specific medical issues at hand.
What is the time limit for a QME to schedule an examination after the initial request for an appointment?
The QME must schedule the examination within ninety (90) days of the initial request. If the 90-day scheduling limit has been waived pursuant to section 31.3e of Title 8 of the California Code of Regulations then the exam cannot be scheduled within one hundred twenty (120) days of the initial request.
What must happen if the injured worker changes their residence address after the QME panel has been issued?
If the injured worker has changed their residence address since the QME panel was issued and prior to the date of the initial evaluation this may affect the scheduling of the examination.
Define ‘group practice’ as it relates to the QME panel under Labor Code section 139.3.
A group practice refers to a group of two or more physicians who share the same facility and who provide healthcare services. If a physician on the QME panel is a member of the same group practice as another QME on the panel it could impact the scheduling of the examination.
What are the conditions under which a QME may be deemed ‘unavailable’?
A QME may be deemed unavailable under section 33 which outlines specific circumstances when they cannot fulfill their duties affecting scheduling.
What should be done if the evaluator who previously reported in the case is no longer available?
If the evaluator who previously reported in the case is no longer available this may create a need for rescheduling the examination or finding a substitute evaluator.
Under what conditions can a QME named on the panel not serve if they were the employee’s primary or secondary treating physician?
If a QME named on the panel is currently or has been the employee’s primary treating physician or secondary physician in relation to the injury then they cannot serve in that capacity according to section 9785 of Title 8 of the California Code of Regulations.
What is the role of a QME (Qualified Medical Evaluator) in the California workers’ compensation system?
The role of a QME is to provide an independent medical evaluation of an injured worker to determine the extent and cause of their injuries medical treatment needs and disability status.
Describe the implications of using a doctor related by practice on a QME panel.
The presence of multiple QME panel members related by practice in the same group may lead to biases or conflicts of interest potentially affecting the fairness and objectivity of the evaluation.
What is the significance of sections 31.3e and 33 in scheduling QME examinations?
Section 31.3e addresses the conditions under which the 90-day scheduling limit can be waived while section 33 specifies the conditions that define a QME’s unavailability both of which are critical for understanding scheduling procedures.
What legal text outlines requirements for allowable delays in scheduling QME examinations?
The requirements and allowances for delays are outlined in Title 8 of the California Code of Regulations.
What is the role of the claims administrator in relation to the replacement panel for an employee’s convenience?
The claims administrator or the employer if there is none may agree in writing with the employee that a new panel can be issued in the Geographic Area of the Employee’s Work Place. A copy of the employee’s agreement must be submitted with the panel replacement request.
What is required for the Medical Director to find ‘good cause’ for replacing a Qualified Medical Evaluator (QME) or panel?
The Medical Director must receive a written request and find good cause related to the medical nature of the injury. ‘Good cause’ is defined as a documented medical or psychological impairment.
What documentation must accompany the Medical Director’s written request when seeking a replacement QME or panel?
The written request must include a copy of the Doctor’s First Report of Occupational Injury or Illness (Form DLSR 5021) as per 8 Cal. Code Regs. 14006 and 14007 as well as the most recent DWC Form PR-2 ‘Primary Treating Physician’s Progress Report’ as per 8 Cal. Code Regs. 9785.2 or a narrative report filed in lieu of these forms.
What does ‘good cause’ refer to in the context of requesting a replacement QME?
‘Good cause’ refers to a documented medical or psychological impairment that justifies the need for a replacement Qualified Medical Evaluator (QME) or panel.
What forms are referenced in the requirement for the Medical Director’s replacement request?
The forms referenced are the Doctor’s First Report of Occupational Injury or Illness (Form DLSR 5021) and the DWC Form PR-2 ‘Primary Treating Physician’s Progress Report’.
What regulations govern the requirements for forms related to occupational injury reports in California?
The requirements for forms related to occupational injury reports in California are governed by 8 Cal. Code Regs. 14006 14007 and 9785.2.
What is the significance of submitting an employee’s signed agreement for a new panel?
The submission of the employee’s signed agreement is significant as it validates the convenience request for a new panel in the appropriate geographic area and is required to be included with the panel replacement request.
Who decides if there is ‘good cause’ for a replacement QME or panel?
The decision on whether there is ‘good cause’ for a replacement QME or panel is made by the Medical Director.
What does PR-2 determine regarding the specialty chosen by the party holding the legal right?
PR-2 determines that the specialty chosen by the party holding the legal right to designate a specialty is medically or otherwise inappropriate for the disputed medical issues.
What can the Medical Director request from either party in PR-2 evaluations?
The Medical Director may request either party to provide additional information or records necessary for the determination.
What section does the evaluator violate if they do not comply with Appointment Notification and Cancellation?
The evaluator has violated section 34 Appointment Notification and Cancellation of Title 8 of the California Code of Regulations.
Under what condition will the evaluator not be replaced due to the violation of section 34?
The evaluator will not be replaced for this reason whenever the request for a replacement by a party is made more than fifteen (15) calendar days from either the date the party became aware of the violation of section 34 or the date the report was served by the evaluator whichever is earlier.
What deadlines are specified that the evaluator failed to meet?
The evaluator failed to meet the deadlines specified in Labor Code section 4062.5 and section 38 Medical Evaluation Time Frames of Title 8.
What is the purpose of section 34 of Title 8 of the California Code of Regulations?
Section 34 of Title 8 of the California Code of Regulations pertains to the notification and cancellation of appointments related to medical evaluations.
What does Labor Code section 4062.5 pertain to?
Labor Code section 4062.5 pertains to the requirements and timelines for medical evaluations in the workers’ compensation sector.
What are the implications of not adhering to Medical Evaluation Time Frames in Title 8?
Not adhering to Medical Evaluation Time Frames can lead to delays in the resolution of medical disputes and may affect the legal proceedings regarding workplace injuries.
What is the significance of a party becoming aware of a violation?
The significance of a party becoming aware of a violation is critical as it triggers the timeline for requesting a replacement evaluator under section 34 of Title 8.
