5. QME Availability and Reports 3 Flashcards
What must a party requesting a replacement do if they object to a report on the basis of lateness?
The party requesting a replacement must attach a copy of their objection to the untimely report along with their request for a replacement.
What is the disqualifying conflict of interest defined in?
The disqualifying conflict of interest for a Qualified Medical Evaluator (QME) is defined in section 41.5 of Title 8 of the California Code of Regulations.
What order can the Administrative Director issue regarding a QME evaluation?
The Administrative Director can issue an order for additional QME evaluation pursuant to section 10164c of Title 8 of the California Code of Regulations.
What happens if a selected medical evaluator refuses to provide a complete medical evaluation when requested?
If the selected medical evaluator refuses to provide a complete medical evaluation as provided in Labor Code sections 4062.3i and 4062.3k they must provide a written statement that explains why they believe they are not medically qualified.
What is the purpose of the Labor Code sections 4062.3i and 4062.3k?
Labor Code sections 4062.3i and 4062.3k outline the requirements and procedures for medical evaluations in the context of workers’ compensation claims.
What is the impact of a QME having a disqualifying conflict of interest?
A QME with a disqualifying conflict of interest may be deemed unqualified to conduct the evaluation potentially resulting in the invalidation of their report or requiring a replacement evaluator.
What documentation is required to support a replacement request based on an evaluator’s untimely report?
The request for replacement must include a copy of the objection to the untimely report.
What can a party do if they believe the QME is not qualified to evaluate their case?
They can either request a complete medical evaluation or ask the QME to provide a written statement explaining their lack of qualification.
Where can the guidelines regarding QMEs be found?
Guidelines regarding QMEs can be found in Title 8 of the California Code of Regulations.
In what scenario might a party request a replacement QME?
A party might request a replacement QME if they believe the current evaluator has a conflict of interest the report is untimely or the evaluator refuses to provide necessary documentation or evaluations.
What is the validity criterion for the QME panel list in relation to the request for a replacement?
The QME panel list must have been issued more than twenty-four (24) months prior to the date the request for a replacement is received by the Medical Unit and none of the QMEs on the panel list can have examined the injured worker.
What happens when the Medical Director determines a request for a QME or QME panel replacement is valid?
When the Medical Director determines that a request for a QME replacement or QME panel replacement is valid the time limit for an unrepresented employee to select a QME and schedule an appointment under Labor Code section 4062.1c and the time limit for a represented employee to strike a QME name from the QME panel under Labor Code section 4062.2c shall be tolled until the replacement QME name or QME panel is issued.
What occurs if parties in a represented case have struck two QME names from a panel and a valid ground arises for replacement?
If the parties in a represented case have struck two QME names from a panel and thereafter a valid ground under subdivision 31.5 arises to replace the remaining QME none of the QMEs whose names appeared on the panel can be considered for replacement.
Define QME in the context of this document.
QME stands for Qualified Medical Evaluator a medical professional authorized to perform evaluations and provide expert opinions in medical disputes especially within workers’ compensation cases.
What are the implications of a QME replacement request in the context of time limits for injured workers?
The implications are that once a replacement request is determined to be valid the time limits for both unrepresented and represented injured workers concerning the selection and striking of QMEs are paused until the new QME is appointed.
What is Labor Code section 4062.1c about?
Labor Code section 4062.1c pertains to the selection of a QME and the scheduling of an appointment by an unrepresented employee.
What does Labor Code section 4062.2c address?
Labor Code section 4062.2c addresses the process by which a represented employee can strike a QME name from the QME panel.
What is the significance of the time limit concerning the panel list in a QME replacement request?
The significance is that the panel list must be current (not issued more than 24 months prior) and that no previous evaluations have taken place by the QMEs on that list for the request for a replacement to be considered valid.
How many QME names can be struck from a panel in a represented case before a valid ground for replacement must be found from other sources?
In a represented case two QME names can be struck from a panel; thereafter any valid ground for replacement must find only QMEs not previously on that panel.
What are potential grounds that could validate a QME replacement request under subdivision 31.5?
While specific grounds are not detailed in the text provided generally these could include conflicts of interest biases unavailability of the QME or the QME’s inability to conduct an evaluation effectively.
What is the protocol after a Qualified Medical Evaluator (QME) issues a medical-legal report in a case when a new medical dispute arises?
Once an Agreed Medical Evaluator an Agreed Panel QME or a panel Qualified Medical Evaluator has issued a comprehensive medical-legal report in a case and a new medical dispute arises the parties shall obtain a follow-up evaluation or a supplemental evaluation from the same evaluator to the extent possible.
What constitutes ‘good cause’ for obtaining an additional QME panel in a different specialty?
Good cause means a written agreement by the parties in a represented case that there is a need for an additional comprehensive medical-legal report by an evaluator in a different specialty.
Under what circumstances can the Medical Director issue an additional panel of QME physicians in a different specialty?
The Medical Director can issue an additional panel of QME physicians in a different specialty upon showing good cause which is defined as having a written agreement by the parties that an additional evaluation is necessary to reach an expeditious and just resolution of disputed medical issues in the case.
What should the parties do before seeking an additional QME panel in a different specialty?
Before seeking an additional QME panel in a different specialty the parties should determine if it is possible to obtain a follow-up or supplemental evaluation from the same evaluator who issued the prior medical-legal report.
What does it mean to have an ‘Agreed Medical Evaluator’ in the context of QME panels?
An Agreed Medical Evaluator is a medical professional who has been mutually selected by the parties involved in a workers’ compensation case to perform a medical evaluation and provide a comprehensive report on the medical issues.
What is the main purpose of obtaining a replacement QME panel?
The main purpose of obtaining a replacement QME panel is to ensure that disputes regarding medical issues in a case can be resolved fairly and quickly particularly when the original panel does not adequately address all necessary specialties.
In a represented case how does the agreement of the parties facilitate the QME process?
In a represented case the written agreement of the parties facilitates the QME process by demonstrating consensus on the necessity of an additional evaluation from a different specialty which assists the Medical Director in its decision to issue a new panel.
What happens if the parties do not agree to an additional evaluation?
If the parties do not agree to an additional evaluation they may proceed with the evaluation obtained from the original QME or seek alternative means of resolution according to the established procedures.
What are the conditions under which parties may agree upon an additional evaluation by a QME physician?
- The parties have a specific specialty in mind that they have agreed upon for the additional evaluation. 2. An acupuncturist has referred the parties to the Medical Unit for an additional panel due to disability being in dispute. 3. An order by a Workers’ Compensation Administrative Law Judge for a panel of QME physicians designating a party to select the specialty or stating the specialty to be selected along with the relevant zip code for evaluator selection. 4. In unrepresented cases the parties have conferred with an Information and Assistance Officer and reached an agreement in the presence of the officer regarding the need for an additional QME evaluator in a different specialty.
What is the role of the Information and Assistance Officer in the context of acupuncture referrals?
The Information and Assistance Officer can communicate either in person or by conference call to provide guidance regarding the acupuncture referrals process.
What is required when an injured worker selects an acupuncturist from a three-member panel?
If an injured worker has selected an acupuncturist from a three-member panel and there is a dispute over disability the acupuncturist must inform the parties involved that another specialty is needed to assess the disability and then refer them to the Medical Unit to request an additional panel.
What type of issues must the acupuncturist evaluate?
The acupuncturist is required to evaluate all other issues necessary for a comprehensive assessment even if an additional specialty is requested for disability evaluation.
Can a Qualified Medical Evaluator (QME) obtain a consultation for permanent disability opinions?
No except where specifically provided a QME cannot seek a consultation for the purpose of acquiring an opinion on permanent disability and apportionment in accordance with Labor Code sections 4660 to 4664 and the AMA Guides.
What happens when the Appeals Board orders additional Qualified Medical Evaluator (QME) evaluations?
Upon receipt of an order from the Appeals Board the Medical Director is responsible for issuing a panel of Qualified Medical Evaluators.
What is the significance of Labor Code sections 4660 through 4664 in the context of permanent disability evaluations?
Labor Code sections 4660 through 4664 provide the guidelines and requirements for determining permanent disability and apportionment which must be followed by Qualified Medical Evaluators.
What is the function of the AMA Guides in relation to disability evaluations?
The AMA Guides are used to establish standards and criteria for evaluating permanent disabilities ensuring consistent and accurate assessments in accordance with established legal and medical frameworks.
What must be done if an acupuncturist determines that another specialty is needed for an evaluation?
The acupuncturist must notify the involved parties and refer them to the Medical Unit for an additional panel request ensuring that a proper disability assessment can be conducted.
When might a Medical Director issue a panel of Qualified Medical Evaluators?
A Medical Director will issue a panel of Qualified Medical Evaluators upon receiving an order from the Appeals Board for additional evaluations.
What is a Qualified Medical Evaluator (QME) in Workers’ Compensation?
A QME is a physician who is certified by the state to evaluate injured workers and provide impartial medical opinions on the nature and extent of their injuries treatment recommendations and the ability of the injured worker to work.
Under which Labor Code sections can additional evaluations be deemed reasonable and necessary?
Additional evaluations can be considered reasonable and necessary under Labor Code sections 4060 4061 and 4062.
What information must an order from a Workers’ Compensation Administrative Law Judge or the Appeals Board contain regarding a QME panel?
The order must specify the residential or employment-based zip code for randomly selecting evaluators the specialty required for the QME panel and the process for selecting a new specialty if there are too few QMEs in the initially selected specialty in accordance with section 31d of Title 8 of the California Code of Regulations.
What is the protocol for a QME who will be unavailable to perform evaluations for an extended period?
A QME who will be unavailable to schedule or perform comprehensive medical evaluations for 14 days or up to a maximum of 120 days during a calendar year must notify the Medical Director by submitting the ‘Notice of Qualified Medical Evaluator Unavailability’ form at least 30 days before the unavailability period.
What is the maximum period for which a QME can be unavailable during a calendar year?
A QME can be unavailable for up to a maximum of 120 days during a calendar year.
What is the significance of specifying the zip code in the QME panel order?
Specifying the zip code for the QME panel ensures that the evaluators selected are geographically reasonable for the injured party facilitating the accessibility of medical evaluations.
Who is responsible for selecting a new specialty for a QME panel in case of unavailability?
The process for selecting a new specialty if there are too few QMEs in the initially selected specialty is outlined in section 31d of Title 8 of the California Code of Regulations; it is typically managed by the Medical Director.
What is section 31d of Title 8 of the California Code of Regulations related to?
Section 31d of Title 8 pertains to the procedural guidelines for the selection of specialties for QME panels when the initial specialty lacks adequate evaluators.
What is the ‘Notice of Qualified Medical Evaluator Unavailability’ form?
The ‘Notice of Qualified Medical Evaluator Unavailability’ form is a document that a QME must fill out and submit to notify the Medical Director of their inability to perform evaluations for a specified period.
How many days in advance must a QME notify the Medical Director of their unavailability?
A QME must notify the Medical Director at least 30 days before the period of unavailability.
What does it mean when a QME requests unavailability status?
When a Qualified Medical Evaluator (QME) requests unavailability status it means they are notifying the Medical Director that they cannot take on new medical-legal evaluation appointments due to specific reasons which may include personal or professional obligations.
Who has the authority to grant unavailability status to a QME?
The Medical Director has the discretion to grant unavailability status to a QME.
What are some examples of good cause for granting unavailability status?
Examples of good cause for granting unavailability status include medical emergencies family emergencies or the QME’s inability to schedule new medical-legal evaluation appointments within 90 days because of existing commitments.
What constitutes a ‘new medical-legal evaluation appointment’?
A ‘new medical-legal evaluation appointment’ is one that is not currently scheduled at the time the QME requests unavailability status.
Are both Comprehensive Medical-Legal Evaluations and Follow-Up Medical-Legal Evaluations considered new appointments?
Yes both Comprehensive Medical-Legal Evaluations and Follow-Up Medical-Legal Evaluations are considered new medical-legal evaluation appointments for the purpose of the unavailability status.
What must a QME provide when requesting unavailability status?
When requesting unavailability status the QME must provide the Medical Director with a list of all comprehensive medical-legal evaluation examinations already scheduled during the time requested for unavailability.
What is the notice period for requesting unavailability status?
There is a 30-day notice period for the QME to request unavailability status.
What is the significance of the 90-day time frame in relation to new appointments for QME?
The 90-day time frame refers to the period within which a QME should schedule new medical-legal evaluation appointments and if they are unable to do so due to prior commitments they may request unavailability status.
What must a QME indicate about examinations during their unavailable status?
The QME must indicate whether each examination is being rescheduled or if they plan to complete the exam and report while in unavailable status.
Under what condition can a QME who is currently unavailable perform new evaluation examinations?
A QME who is unavailable due to subdivision a shall not perform any new evaluation examinations until they return to active QME status.
Can a QME complete examinations and reports that were already scheduled before they became unavailable?
Yes a QME can complete medical-legal examinations and reports already scheduled and reported to the Medical Director as well as reports for evaluation examinations performed prior to becoming unavailable.
What types of reports may a QME complete while in unavailable status?
A QME may complete supplemental reports while in unavailable status.
Is it an acceptable reason for a QME’s unavailability if they do not intend to perform evaluations for unrepresented workers?
No it is not an acceptable reason for unavailability that a QME does not intend to perform comprehensive medical-legal evaluations for unrepresented workers.
What consequence can occur if a QME has filed notifications for unavailability totaling more than 120 days in a calendar year without good cause?
A QME may be denied reappointment subject to section 51a3.
Define ‘good cause’ as it relates to a QME’s unavailability status.
The document did not provide a definition for ‘good cause’; however it implies that unavailability must be justifiable and substantiated to exceed the threshold of 120 days.
What are some reasons for a Qualified Medical Evaluator (QME) to become unavailable?
Reasons can include sabbaticals death or serious illness of an immediate family member.
What must a QME do if they are going to be unavailable?
The QME must notify the Medical Director by submitting the form in section 109 Notice of Qualified Medical Evaluator Unavailability at least 30 days prior to the period of unavailability.
What happens if a QME does not notify the Medical Director in a timely manner?
If the QME fails to notify the Medical Director at least 30 days in advance the Medical Director may designate the QME to be unavailable at that location for 30 days from the date they learn of the unavailability.
What action does the Medical Director take if they become aware that a QME is not available?
The Medical Director will send a certified letter to the QME regarding their unavailability.
What is the timeframe for the QME to respond to the Medical Director after receiving the certified letter?
The QME must respond within 15 days of the date the certified letter is sent.
What is the role of the Medical Director in the context of QME unavailability?
The Medical Director is responsible for managing QME unavailability notifications and may take action if the QME does not respond or notify in a timely manner.
What is the purpose of the form in section 109 Notice of Qualified Medical Evaluator Unavailability?
The purpose of the form is to officially inform the Medical Director about the unavailability of a QME.
