5. QME Availability and Reports 6 Flashcards
What is the role of the Medical Director in cases of communication violations?
The Medical Director’s role includes providing the aggrieved party with a new panel if there is a violation of communication protocols maintaining the integrity of the evaluation process.
What is the context in which an employee’s dependent may be involved in an evaluation?
An employee’s dependent may be involved in evaluations related to the employee’s claims examinations or requests made in connection with the examination. However the involvement of the dependent in such evaluations does not warrant a new evaluator unless there is a specific finding of impermissible ex parte communication by the Appeals Board.
What circumstance allows for the selection of separate Qualified Medical Evaluators (QMEs)?
In claims involving a date of injury prior to 11/2005 if the injured worker is represented by an attorney and the parties involved decide to each select a separate Qualified Medical Evaluator the provisions regarding communications between a party and the QME selected by that party will not apply.
What are the Labor Code sections that pertain to evaluations completed under Administrative Director Evaluation and Reporting Guidelines?
The Labor Code sections that pertain to evaluations completed under the Administrative Director Evaluation and Reporting Guidelines are sections 4060 4061 4062 4062.1 4062.2 4064 4067 and 5703.5.
What is required of the evaluation examination and report according to the guidelines?
Each evaluation examination and report must be completed in compliance with all appropriate evaluation procedures set forth in the relevant chapter of the Labor Code.
What should each reporting evaluator include in their report?
Each reporting evaluator is required to state specific information in the body of their report following the compliance and evaluation procedures established by the relevant guidelines.
What is ex parte communication in the context of evaluations?
Ex parte communication refers to any communication with one party that occurs without the presence or knowledge of other involved parties which can lead to bias or unfairness in the evaluation process.
What entity is responsible for determining if ex parte communication occurred in evaluation cases?
The Appeals Board is responsible for making findings regarding whether any impermissible ex parte communication occurred in the context of evaluations.
What is the significance of the date of injury being prior to 11/2005 in this context?
The significance of the date of injury being prior to 11/2005 is that it allows the injured worker who is represented by an attorney to choose separate Qualified Medical Evaluators without the constraints applied to communications when evaluations are standard.
What information must be included in a comprehensive medical-legal report regarding the examination?
The report must include the date the examination was completed and the street address at which the examination was performed.
What should the evaluator do if they sign the report on a date other than the examination date?
The evaluator shall still address all contested medical issues arising from all injuries reported on one or more claim forms prior to the date of the employee’s appointment with the medical evaluator.
What types of issues should the evaluator address in the report?
The evaluator should address issues within their scope of practice and areas of clinical competence as well as respond to questions raised by each party in the issue cover letter.
What is required in the Physician’s Report of Permanent and Stationary Status and Work Capacity DWC-AD Form 10133.36?
If the evaluator declares the injured worker permanent and stationary for the body part evaluated and finds that the injury has caused permanent partial disability the evaluator must complete this form.
Who must receive the completed Physician’s Report of Permanent and Stationary Status and Work Capacity DWC-AD Form 10133.36?
The completed form must be served on the claims administrator.
What is meant by ‘permanent and stationary’ in the context of an evaluation?
‘Permanent and stationary’ refers to a condition where the injured worker’s medical condition has stabilized and no significant improvement is expected with further treatment.
What are ‘contested medical issues’ in a medical-legal case?
Contested medical issues are disagreements regarding the nature extent and causation of the injuries typically involving differing opinions from medical evaluators.
What are the responsibilities of the reporting evaluator in addressing contested issues?
The reporting evaluator must attempt to address each question raised by the parties involved in the issue cover letter ensuring a thorough evaluation.
What must be considered when determining ‘permanent partial disability’?
The evaluator should consider the extent of the injury and its impact on the injured worker’s ability to perform work-related tasks.
What is the implication of the evaluator’s findings on permanent partial disability for the employee?
The findings can affect the employee’s eligibility for disability benefits and potentially influence the settlement of their claim.
What is the role of the claims administrator in the context of medical evaluations?
The claims administrator is responsible for managing the claims process and must receive relevant documentation including the Physician’s Report.
What should the evaluator do upon identifying disputed medical issues outside of their scope of practice?
The evaluator should advise the parties in writing of any disputed medical issues outside of their scope of practice and area of clinical competency at the earliest opportunity and no later than the date the report is served.
What sections of the Labor Code allow parties to initiate the process for obtaining an additional evaluation?
The parties may initiate the process for obtaining an additional evaluation pursuant to section 4062.1 or 4062.2 of the Labor Code.
In the case of a panel QME what is the requirement regarding notification?
In the case of a panel QME the evaluator shall send a copy of the written notification to the parties to the Medical Director at the same time.
What actions will the Medical Director take upon a party’s request for an additional panel?
The Medical Director will act upon a party’s request for an additional panel only if the evaluator’s written notice is attached or if there is an order by a Workers’ Compensation Administrative Law Judge.
