5. QME Availability and Reports 4 Flashcards
How far in advance must a QME notify the Medical Director about their unavailability?
A QME must notify the Medical Director at least 30 days in advance of their unavailability.
What is the consequence of not responding to the Medical Director’s certified letter about unavailability?
The document does not specify consequences but failing to respond may affect the QME’s professional standing or availability.
When may the Medical Director designate a QME as unavailable?
The Medical Director may designate a QME as unavailable if they are not informed about the unavailability at least 30 days prior to the period of unavailability.
What happens after a letter is mailed regarding a QME status?
Once a letter is mailed the QME will be made unavailable at that location. This status will count towards the one hundred and twenty (120) day limit specified in section 33a.
What is the time limit for a QME’s unavailable status as per the provided text?
The time a QME is placed on unavailable status counts towards the one hundred and twenty (120) day limit in section 33a.
What is required whenever an appointment for a comprehensive medical evaluation is made with a QME?
Whenever an appointment is made with a QME the QME must complete an appointment notification form as outlined in Section 110 QME Appointment Notification Form found in 8 Cal. Code Regs. 110.
What is the timeframe in which the appointment notification form must be submitted?
The completed appointment notification form shall be postmarked or sent by facsimile to relevant parties within 5 business days of the date the appointment was made.
Who must receive the appointment notification form in a represented case?
In a represented case a copy of the completed appointment notification form must also be sent to the attorney who represents each party if known.
What constitutes grounds for denial of reappointment under section 51 of Title 8?
Failure to comply with the requirement of submitting the appointment notification form within the specified timeframe constitutes grounds for denial of reappointment under section 51 of Title 8 of the California Code.
What does QME stand for?
QME stands for Qualified Medical Evaluator.
What is the significance of section 51 of Title 8 of the California Code?
Section 51 of Title 8 of the California Code outlines regulations regarding the reappointment of QMEs and the necessary compliance requirements that must be adhered to.
What is the role of the Qualified Medical Evaluator (QME) in the scheduling of comprehensive medical-legal examinations?
The QME is responsible for scheduling the first comprehensive medical-legal examination which must be conducted at a medical office listed on the panel selection form or any office approved by the Medical Director with written agreement from the parties.
Can subsequent evaluation appointments be held at different medical offices?
Yes subsequent evaluation appointments may be performed at another medical office of the selected QME provided it is listed with the Medical Director and is within a reasonable geographic distance from the injured worker’s residence.
What must the QME include in the notification regarding interpreting services?
The QME must include whether a Certified Interpreter is required as defined by Labor Code Section 5811 and must specify the language needed.
Who arranges for the Certified Interpreter and who pays for it?
The party responsible for paying the cost of the interpreter must arrange for the Certified Interpreter as outlined in Section 5811 of the Labor Code.
What does ‘AME’ stand for in the context of medical evaluations?
‘AME’ stands for Agreed Medical Evaluator which is another type of medical evaluator alongside the QME.
What section of the California Code of Regulations defines the need for a Certified Interpreter?
The need for a Certified Interpreter is defined in section 9795.3 of Title 8 of the California Code of Regulations.
What is a key requirement for the location of the first comprehensive medical-legal examination?
The first comprehensive medical-legal examination must be held at a medical office listed on the panel selection form or an alternate office approved by the Medical Director with written agreement from both parties.
What is the significance of Labor Code Section 5811 in the context of medical evaluations?
Labor Code Section 5811 outlines the requirements and responsibilities regarding the use and costs associated with Certified Interpreters for injured workers during medical-legal evaluations.
How far must a subsequent medical evaluation location be from the injured worker’s residence?
The subsequent medical evaluation must be at a reasonable geographic distance from the injured worker’s residence according to the provisions set by the QME or AME.
What does the acronym QME stand for?
QME stands for Qualified Medical Evaluator.
What is the rule regarding canceling a scheduled appointment less than six business days before the appointment?
An appointment cannot be canceled less than six business days prior to the appointment date except for good cause.
What must an evaluator do if they cancel a scheduled appointment?
The evaluator must advise the parties in writing of the reason for the cancellation.
Who retains jurisdiction to resolve disputes regarding appointment cancellations?
The Appeals Board retains jurisdiction to resolve disputes among the parties regarding whether an appointment cancellation was for good cause.
What authority does the Administrative Director have concerning QMEs?
The Administrative Director retains jurisdiction to take appropriate disciplinary action against any QME (Qualified Medical Evaluator) for violations of the cancellation section.
What is the requirement for rescheduling an appointment after cancellation by a QME or AME?
A QME or AME who cancels a scheduled appointment must reschedule the appointment within sixty (60) calendar days of the date of the cancellation unless the parties agree in writing to accept an appointment beyond this limit.
What happens if a QME or AME cancels an appointment?
They must reschedule the appointment within sixty (60) calendar days unless there is written agreement from the parties for a later date.
What must be done if relevant medical records are not received before a scheduled appointment?
The pertinent sections of Title 8 of the California Code of Regulations and section 4062.3 of the Labor Code provide regulations regarding the necessity and handling of medical records prior to a scheduled appointment.
Are there exceptions to the rule about canceling appointments less than six business days in advance?
Yes there are exceptions for good cause.
What constitutes ‘good cause’ for canceling an appointment?
‘Good cause’ is not explicitly defined in the provided text but generally refers to a valid or justifiable reason for the cancellation.
What documentation is required when a QME cancels an appointment?
A written explanation must be provided to the involved parties regarding the reason for the cancellation.
What constitutes good cause for an evaluator to cancel an appointment under this section?
Good cause for an evaluator to cancel an appointment only applies when the evaluator is a psychiatrist or psychologist conducting an evaluation regarding a disputed injury to the psyche and states in the evaluation report that receipt of relevant medical records prior to the evaluation was necessary for a full and fair evaluation.
What is the minimum notice period required to cancel or reschedule an appointment with an evaluator?
An appointment with an evaluator whether it is an AME Agreed Panel QME or QME shall not be cancelled or rescheduled by a party or their attorney less than six (6) business days before the appointment date except for good cause.
What actions must be taken if a claims administrator employer injured worker or a party’s attorney cancels an appointment with an evaluator?
If an appointment is cancelled it must be done in writing state the reason for the cancellation and serve this notice on the opposing party. Additionally if the cancellation was made orally it must be followed up with a written confirming letter that is either faxed or mailed.
What types of evaluators are referenced in the document?
The document references three types of evaluators: Agreed Medical Evaluator (AME) Agreed Panel Qualified Medical Evaluator (QME) and Qualified Medical Evaluator (QME).
What should be included in the written notice for a cancellation of an appointment?
The written notice for a cancellation of an appointment must include: the reason for the cancellation and it must be served on the opposing party.
What does AME stand for in the context of evaluating claims?
AME stands for Agreed Medical Evaluator.
What does QME stand for in the context of this document?
QME stands for Qualified Medical Evaluator.
What is the significance of having medical records prior to an evaluation by a psychiatrist or psychologist?
The significance lies in the requirement that the evaluator states in their report that receiving relevant medical records prior to the evaluation is necessary to conduct a full and fair evaluation of disputed psychological injuries.
Can a party’s attorney cancel an appointment with less than six business days’ notice?
No a party’s attorney cannot cancel an appointment with less than six (6) business days’ notice unless there is good cause.
What process follows an oral cancellation of an appointment?
An oral cancellation must be followed by a written confirming letter that is either faxed or mailed.
What is the time frame for sending a written cancellation after a verbal cancellation?
The written cancellation must be sent by first class U.S. mail within twenty-four hours of the verbal cancellation.
Is an injured worker liable for missed appointment fees if the appointment is cancelled for good cause?
No an injured worker shall not be liable for any missed appointment fee if the appointment is cancelled for good cause.
Who retains jurisdiction to resolve disputes regarding appointment cancellations?
The Appeals Board retains jurisdiction to resolve disputes regarding whether an appointment cancellation was for good cause.
How is the date of cancellation determined if the cancellation is mailed?
The date of cancellation is determined from the date of postmark if mailed.
How is the date of cancellation determined if using facsimile communication?
The date of cancellation is determined from the facsimile receipt date as shown on the recipient’s fax copy.
What information must the claims administrator or employer provide to the evaluator?
The claims administrator or the employer if none shall provide the following information to the evaluator: 1. All records prepared or maintained by the employee’s treating physician(s). 2. Other relevant medical records including any previous treatment records or information.
What does AME stand for in the context of workers’ compensation?
AME stands for Agreed Medical Evaluator.
What does QME stand for in the context of workers’ compensation?
QME stands for Qualified Medical Evaluator.
What is required when a medical determination is made regarding a dispute?
A letter outlining the medical determination of the primary treating physician or the compensability issues that the evaluator is requested to address must be served on the opposing party no less than 20 days in advance of the evaluation.
For evaluations regarding injuries before January 1 2013 what conditions apply concerning disputes over utilization review decisions?
If the decision is communicated to the requesting physician on or before June 30 2013 and if the treating physician’s recommended medical treatment is disputed relevant documents must include: a copy of the treating physician’s report recommending medical treatment a copy of the claims administrator’s or employer’s decision to approve delay deny or modify the disputed treatment and all relevant communications exchanged during the utilization review.
What documents must be provided if the treating physician’s recommended treatment is disputed?
A copy of the treating physician’s report recommending the medical treatment a copy of the claims administrator’s or the employer’s decision regarding the disputed treatment and all supporting documents and relevant communications regarding the treatment.
What is the time frame for serving the letter of medical determination before an evaluation?
The letter must be served on the opposing party no less than 20 days in advance of the evaluation.
What is the significance of the June 30 2013 date in regards to injuries and utilization review?
If the evaluation is for injuries that occurred before January 1 2013 the June 30 2013 date is crucial as it is the cut-off for when the decision to the requesting physician regarding the recommended treatment must be communicated in order for the associated documents and communications to be required.
In a dispute involving a treatment recommendation what types of documents can be classified as relevant communications?
Relevant communications can include any communication exchanged during the utilization review about the disputed treatment including emails letters reports and any documentation submitted or received concerning the treatment recommendation.
What steps should be taken if a decision about medical treatment is denied or modified?
The steps include ensuring the claims administrator or employer’s decision is documented along with supporting documents and serving these documents as part of the dispute resolution.
What is the process required by Labor Code section 4610 regarding non-medical records?
Labor Code section 4610 requires that non-medical records including films and videotapes relevant to the determination of medical issues in dispute must comply with subdivision 35c of Title 8 of the California Code of Regulations.
What exceptions are there to the written communication requirements outlined in Labor Code section 4062.3f?
Labor Code section 4062.3f allows for oral or written communications with an Agreed Medical Evaluator (AME) regarding nonsubstantive matters such as scheduling and missed appointments and communications related to the furnishing of records and availability of reports unless the appeals board finds an impermissible ex parte communication.
What constitutes ‘nonsubstantive matters’ in the context of Labor Code section 4062.3f?
Nonsubstantive matters include issues like scheduling of appointments missed appointments the furnishing of records and reports and inquiries about the availability of the report.
What must parties do when communicating with a medical evaluator according to the Labor Code?
All communications by the parties with the evaluator shall be in writing and sent simultaneously to the opposing party when sent to the medical evaluator barring exceptions noted in subdivisions c k and l of the Labor Code.
What is the significance of ‘ex parte communication’ as mentioned in the Labor Code?
Ex parte communication refers to communication with a decision-maker (like a medical evaluator) without the presence or knowledge of the opposing party. The appeals board must specifically find that such communication is impermissible.
How does Labor Code section 4062.3f modify the need for written communication with an AME?
Section 4062.3f modifies the need for written communication by allowing informal communications regarding non-substantive matters to occur either orally or in writing reducing the strict requirement for formal written communications only.
What types of records are specifically mentioned in Labor Code section 4610 that are relevant to medical disputes?
Non-medical records such as films and videotapes are specifically mentioned in Labor Code section 4610 as being relevant to medical disputes.
What is the purpose of subdivision 35c of Title 8 of the California Code of Regulations as referenced in Labor Code section 4610?
Subdivision 35c of Title 8 of the California Code of Regulations details the process and requirements for submitting non-medical records relevant to medical issue determination in disputes.
What are the general communication requirements between parties and the medical evaluator under the Labor Code?
Generally all communications must be documented in writing and shared with the opposing party simultaneously when contacting the evaluator.
When can a party engage in oral communication with the AME’s staff?
A party can engage in oral communication with the AME’s staff regarding scheduling of appointments missed appointments and other nonsubstantive matters as specified in Labor Code section 4062.3f.
What is an Agreed Medical Evaluator (AME)?
An Agreed Medical Evaluator (AME) is a medical professional who is chosen by both parties (i.e. the injured employee and the claims administrator) to evaluate the employee’s medical condition and determine the extent of their injury in the workers’ compensation process.
What must parties agree on regarding the information to be provided to the AME?
Parties who have selected an Agreed Medical Evaluator must agree on what information is to be provided to the evaluator as part of their agreement.
How many days before information is provided to the AME must it be served on the opposing party?
At least twenty (20) days before the information is provided to the evaluator the party providing such medical and non-medical reports and information must serve it on the opposing party.
