5. QME Availability and Reports 5 Flashcards
What documentation must be attached to the records sent to the opposing party?
The claims administrator shall attach a log to the front of the records and information being sent to the opposing party. This log must identify each record or other information to be sent to the evaluator and list each item in the order it is attached.
Why is it important to notify the injured employee of the option for handling mental health records?
It is important to notify the injured employee of the option for handling mental health records to ensure compliance with legal protections established by Health and Safety Code section 123115b and to maintain confidentiality and privacy regarding sensitive health information.
What are the implications of not serving the information within the specified time frame?
Failing to serve the information to the opposing party within the specified twenty (20) days may result in legal delays challenges in the evaluation process and potentially adverse implications for the party that did not comply with the timeline.
What types of reports and information should be included when serving documents to the AME?
The reports and information served to the AME should include both medical and non-medical reports relevant to the injured employee’s case as agreed upon by both parties.
In the context of workers’ compensation what is the role of the claims administrator?
The claims administrator is responsible for managing the claims process ensuring compliance with legal requirements facilitating communication between parties and providing relevant documentation (including medical records) to the AME and opposing party.
What does ‘unrepresented and represented cases’ refer to in the context of this document?
‘Unrepresented cases’ refer to situations where the injured employee is not represented by an attorney while ‘represented cases’ refer to situations where the injured employee has legal representation. Both types of cases have similar requirements for submitting information to the AME.
What must the injured worker’s attorney provide to the evaluator in a represented case?
The injured worker’s attorney must provide any records or other information to be sent to the evaluator directly from the attorney’s office.
Who is responsible for including specific records to the evaluator if no claims administrator exists?
If there is no claims administrator the employer is responsible for including the specified records to the evaluator.
What is the time limit for the opposing party to object to any non-medical records proposed to be sent to an evaluator?
The opposing party has 10 days to object to any non-medical records or information proposed to be sent to the evaluator.
What happens if the opposing party objects to sending records to the evaluator within the 10-day limit?
If the opposing party objects the records and information shall not be provided to the evaluator unless ordered by a Workers’ Compensation Administrative Law Judge.
What type of medical-legal reports may NOT be forwarded to the evaluator?
- Any medical-legal report that has been rejected as untimely per Labor Code section 4062.5. 2. Any evaluation or consulting report from any physician other than the treating physician the primary treating physician or secondary physician involved in the medical-legal process under Labor Code sections 4060 through 4062 relating to permanent impairment.
What does Labor Code section 4062.5 address?
Labor Code section 4062.5 addresses the timing and acceptance of medical-legal reports specifically the circumstances under which a report may be deemed untimely.
What is the role of a Workers’ Compensation Administrative Law Judge regarding objections to records?
A Workers’ Compensation Administrative Law Judge has the authority to order the provision of records and information to the evaluator if there has been an objection made by the opposing party.
Who can provide reports related to permanent impairment under the Labor Code?
Reports related to permanent impairment can only be provided by the treating physician the primary treating physician the secondary physician or an evaluator involved through the medical-legal process outlined in Labor Code sections 4060 through 4062.
What are the consequences of forwarding rejected reports to the evaluator?
If rejected reports such as untimely medical-legal reports are forwarded to the evaluator it may result in issues with the evaluation process potential delays and could undermine the legitimacy of the information provided.
What is needed for a physician’s report regarding permanent disability to be admissible in California workers’ compensation cases?
A physician’s report regarding permanent disability must be ruled admissible by a Workers’ Compensation Administrative Law Judge.
What happens if a physician’s report is stricken or deemed inadmissible by a Workers’ Compensation Administrative Law Judge?
If a physician’s report is stricken found inadequate or deemed inadmissible by a Workers’ Compensation Administrative Law Judge it cannot be considered in the case.
What can either party use discovery for in the context of California workers’ compensation evaluations?
Either party may use discovery to establish the accuracy or authenticity of non-medical records or information prior to the evaluation.
What is required for records sent to the evaluator in California workers’ compensation cases?
Copies of all records being sent to the evaluator must also be sent to all parties involved unless exempted under certain sections.
What constitutes ex parte communication in California workers’ compensation proceedings?
Ex parte communication occurs when a party fails to send copies of records to all parties but transmits information to the evaluator violating the communication requirements.
What is the time frame in which an unrepresented employee must schedule an appointment after receipt of information?
An unrepresented employee must schedule an appointment within 20 days of receipt of the information.
What is the role of a Workers’ Compensation Administrative Law Judge regarding medical reports in California?
The Workers’ Compensation Administrative Law Judge is responsible for ruling on the admissibility of medical reports and determining whether they can be considered in the evaluation.
Explain the limitations placed on certain medical records or reports according to California workers’ compensation law?
Certain medical records or reports can be stricken or deemed inadmissible if found inadequate by a Workers’ Compensation Administrative Law Judge precluding their use in evaluations.
What actions can be termed as non-compliance in relation to sending information to evaluators in California workers’ compensation situations?
Failure to provide all relevant parties with copies of the records sent to the evaluator is considered non-compliance and is defined as ex parte communication.
What is the significance of records being admitted or struck in California workers’ compensation evaluations?
The admissibility or striking of records in evaluations critically impacts the determination of permanent disability and apportionment outcomes.
What is the time frame for sending medical information according to the subsection c when the employee is unrepresented?
The employer or claims administrator is not required to comply with the 20-day time frame for sending medical information provided that the unrepresented employee is served all non-medical information 20 days prior to the information being sent to the QME.
What must the employer do to ensure the unrepresented employee has an opportunity to object to any non-medical information?
The employer must serve the unrepresented employee with all non-medical information 20 days prior to serving that information on the QME.
If a party fails to provide relevant medical records within how many days after the date of the evaluation what must the evaluator do?
If any party fails to provide relevant medical records within 10 days after the date of the evaluation the evaluator shall complete and serve the report while noting that the relevant records were not received within the required time period.
According to the regulations what should an evaluator do if they do not receive the medical records in time?
The evaluator shall complete and serve the report in compliance with the statutory time frames and note in the report that the records were not received within the required time period.
What is required if relevant medical records are received after the initial evaluation report has been completed?
Upon request by a party or the Appeals Board the evaluator shall complete a supplemental evaluation when the relevant medical records are received.
What section of the California Code of Regulations mandates the time frames for these evaluations?
The time frames for these evaluations are mandated under section 38 of Title 8 of the California Code of Regulations.
What is a QME in the context of these regulations?
A QME or Qualified Medical Evaluator is a medical professional designated to provide evaluations regarding the medical condition and treatment needs of employees in workers’ compensation cases.
Why is it important for the evaluator to note when records were not received in the report?
It is important for the evaluator to note when records were not received in the report to maintain transparency in the evaluation process and to ensure that all parties are aware of any limitations in the information considered during the evaluation.
What does it mean for an employee to be ‘unrepresented’ in this context?
An unrepresented employee is an individual who does not have legal representation or assistance in their workers’ compensation claim proceedings.
What is the significance of non-medical information in the evaluation process?
Non-medical information may include relevant work history or other contextual details that could impact the evaluation and determination of the employee’s condition or benefits.
What is the protocol if an evaluator believes that a review of additional records is sufficient for the employee’s case?
The evaluator need not conduct an additional physical examination of the employee if they believe that a review of the additional records is sufficient.
Can the evaluator consult with the employee’s treating physicians?
Yes the evaluator and the employee’s treating physicians may consult as necessary to produce a complete and accurate report.
What must the evaluator note in the report related to treating physicians?
The evaluator shall note within the report any new or additional information received from the treating physician.
Who retains jurisdiction in disputes regarding objections or ex parte contact in California?
The Appeals Board retains jurisdiction in all cases to determine disputes arising from objections and whether ex parte contact in violation of Labor Code section 4062.3 or Title 8 of the California Code of Regulations has occurred.
What happens if a party communicates with an evaluator in violation of Labor Code section 4062.3?
If any party communicates with an evaluator in violation of Labor Code section 4062.3 the Medical Director shall provide the aggrieved party with a new panel to select a new QME or the aggrieved party may elect to proceed with the original evaluator.
What forms of communication are considered in the context of Labor Code section 4062.3?
Both oral and written communications by the employee or if the employee is deceased their representatives are considered.
What potential consequences exist for violations of ex parte communication rules under California regulations?
Violations of ex parte communication rules may lead to the provision of a new panel to the aggrieved party for selecting a new Qualified Medical Evaluator (QME) ensuring fairness in the evaluation process.
What should be done if new information arises from the treating physician during the evaluation process?
The evaluator is required to document any new or additional information received from the treating physician in the evaluation report.
Is an additional examination mandatory if new records are available?
No an additional physical examination is not mandatory if the evaluator deems the review of additional records sufficient.
