6. QME Availability and Reports Medical legal Expense 1

Question 1

What does ‘medical-legal expense’ include according to section 4620(a)?

Answer 1

Medical-legal expense includes costs and expenses incurred by or on behalf of any party the administrative director or the board. This may cover X-rays laboratory fees other diagnostic tests medical reports medical records medical testimony and interpreter’s fees by a certified interpreter in accordance with Article 8 starting with Section 11435.05 or Section 68566 of the Government Code.

Question 2

What is the purpose of incurring medical-legal expenses?

Answer 2

The purpose of incurring medical-legal expenses is for proving or disproving a contested claim.

Question 3

Define a ‘contested claim’ as per section 4620(b).

Answer 3

A contested claim exists when the employer knows or should reasonably know that the employee is claiming entitlement to a benefit arising from a claimed industrial injury and one of the following conditions exists: 1) The employer rejects liability for the claimed benefit. 2) The employer fails to accept liability for benefits after a reasonable period of time.

Question 4

What signifies an employer’s rejection of liability in the context of a contested claim?

Answer 4

An employer’s rejection of liability signifies that the employer does not accept the responsibility for the claimed benefits related to an employee’s industrial injury.

Question 5

What actions can lead to a contested claim aside from outright rejection of liability?

Answer 5

A contested claim can arise when an employer does not accept liability for benefits even after a reasonable period has passed indicating a lack of timely response to the claim.

Question 6

What happens if an employer fails to respond to a demand for payment of benefits after the statute time period?

Answer 6

If the employer fails to respond to a demand for payment of benefits after the expiration of any time period fixed by statute for the payment of indemnity it may lead to legal consequences potentially making the employer liable for the owed benefits.

Question 7

What constitutes medical-legal expenses in relation to medical reports?

Answer 7

Costs of medical evaluations diagnostic tests and interpreters do not constitute medical-legal expenses unless the medical report is capable of proving or disproving a disputed medical fact crucial for adjudicating the employee’s claim for benefits.

Question 8

What should a judge consider when determining if a medical report meets legal requirements?

Answer 8

A judge must give full consideration to both the substance and the form of the report to determine whether it meets the requirements outlined by applicable statutes and regulations.

Question 9

What is the right of an injured employee who cannot effectively communicate due to language barriers?

Answer 9

If the injured employee cannot effectively communicate with an examining physician because they do not proficiently speak or understand English they are entitled to the services of a qualified interpreter.

Question 10

Define ‘indemnity’ in the context of employer-employee relations.

Answer 10

Indemnity refers to a form of compensation for loss or injury specifically in workers’ compensation where the employer is obligated to provide financial benefits to an employee who has suffered a work-related injury.

Question 11

What legal implications exist if a medical report does not address a disputed medical fact?

Answer 11

If a medical report does not address a disputed medical fact it may not fulfill the criteria for being considered a medical-legal expense potentially impacting the adjudication of the employee’s claim for benefits.

Question 12

What are the responsibilities of a judge regarding medical reports in workers’ compensation cases?

Answer 12

The judge must assess the contents of medical reports and ensure they meet legal standards that require consideration of both their substance and form in the context of the employee’s claim.

Question 13

Explain the importance of language proficiency in medical evaluations for injured employees.

Answer 13

Language proficiency is critical in medical evaluations because it affects the injured employee’s ability to communicate their condition and understand findings. Lack of proficiency can hinder accurate medical assessment and consequently affect the adjudication of claims.

Question 14

What is the role of an interpreter during a medical examination for an injured employee?

Answer 14

An interpreter facilitates communication between the injured employee and the medical personnel during the examination.

Question 15

Who is responsible for paying the costs of interpreter services requested by an injured employee?

Answer 15

The employer or insurance carrier is responsible for paying the costs of interpreter services as per the fee schedule adopted by the administrative director.

Question 16

What is the Section that sets forth the fee schedule for interpreter services?

Answer 16

The fee schedule for interpreter services is set forth in Section 5811.

Question 17

Are employers required to Pay for the services of a provisionally certified interpreter?

Answer 17

No employers are not required to pay for the services of a provisionally certified interpreter unless they consent in advance to the selection of the individual or if the injured worker requires interpreting services in a language not designated under Section 11435.40 of the Government Code.

Question 18

What are the functions that a nurse can perform during the examination of an injured employee?

Answer 18

A nurse can perform non-examinational functions routinely performed by nurses such as taking blood pressure.

Question 19

Who is allowed to examine the injured employee according to the current laws as of January 01 2023?

Answer 19

Only the physician who signs the medical-legal report is allowed to examine the injured employee except for routine functions performed by a nurse.

Question 20

What is defined as nonclerical participation in the examination of an injured employee?

Answer 20

Nonclerical participation refers to activities that are directly related to examining or assessing the injured employee which exclude clerical tasks.

Question 21

What are the main legislative references affecting the examination of injured employees?

Answer 21

The main references include Section 5811 and Section 11435.40 of the Government Code.

Question 22

What should an employer do if an injured worker requires interpreting services in a language other than the designated languages?

Answer 22

The employer must comply with the request and provide interpreting services in the required language.

Question 23

What are the key components of preparing a medical report?

Answer 23

1. Taking a complete history of the patient. 2. Reviewing and summarizing prior medical records. 3. Composing and drafting the conclusions of the report.

Question 24

What specific details must be disclosed in a medical report according to the guidelines?

Answer 24

The report must disclose the following details: a) The date and location of the evaluation performed. b) Whether the physician(s) signing the report actually performed the evaluation. c) Compliance indication with the guidelines established by the administrative director regarding the evaluation and time spent. d) The name and qualifications of each person who performed services related to the report including diagnostic studies.

Question 25

What compliance guidelines must be addressed in the report regarding the evaluation performed?

Answer 25

The report must indicate whether the evaluation performed and the time spent performing the evaluation was in compliance with the guidelines established by the administrative director as outlined in paragraph 5 of subdivision j of Section 139.2 or Section 5307.6.

Question 26

What happens if the report indicates non-compliance with the established guidelines for the evaluation?

Answer 26

If the report discloses that the evaluation performed or the time spent performing the evaluation was not in compliance with the guidelines established by the administrative director further implications or requirements must be followed though the specific actions are not detailed in the provided text.

Question 27

What is included in the 'taking of a complete history' during a medical evaluation?

Answer 27

Taking a complete history typically includes obtaining the patient's medical history family history social history history of present illness review of systems and any other relevant medical information to understand the patient's health background.

Question 28

Why is reviewing and summarizing prior medical records important in the preparation of a report?

Answer 28

Reviewing and summarizing prior medical records is important because it provides context to the current evaluation helps identify any pre-existing conditions informs diagnostic decisions and aids in forming an accurate clinical picture of the patient's health.

Question 29

Who must be identified in the report in connection to the services performed?

Answer 29

The report must disclose the name and qualifications of each person who performed any services in connection with the report which includes diagnostic studies that are not confined to clerical preparation.

Question 30

What is the significance of the qualifications of individuals performing evaluations or services in the medical report?

Answer 30

The qualifications of individuals performing evaluations or services are significant as they help establish credibility and accountability for the evaluation conducted. It assures that the methods and assessments used in the report are anchored by qualified professionals.

Question 31

What is the role of administrative director's guidelines in the context of the evaluation report?

Answer 31

The administrative director's guidelines serve as standards that ensure evaluations are performed consistently and with appropriate methods time allocation and professional qualifications maintaining quality in medical assessments and reports.

Question 32

In the context of medical reports what is meant by 'compliance'?

Answer 32

Compliance refers to adhering to the established guidelines and standards set forth by regulatory bodies or administrative authorities ensuring that evaluations are carried out properly within the defined rules.

Question 33

What is the significance of a physician reviewing the initial outline of a patient's history or excerpts of prior medical records?

Answer 33

The physician's review of the initial outline of a patient's history or excerpts of prior medical records is crucial to ensure accurate understanding of the patient's medical background. This review allows the physician to identify any gaps in information and make necessary inquiries and examinations to determine relevant medical issues. This process is vital for accurate diagnosis and appropriate treatment.

Question 34

What should a physician do if the initial outline of a patient's history is not completed by them?

Answer 34

If the initial outline of a patient's history or the excerpting of prior medical records is not done by the physician the physician is required to review the excerpts and the entire outline. Following the review the physician must make any additional inquiries and examinations deemed necessary to appropriately identify and determine the relevant medical issues.

Question 35

What constitutes direct charges for a physician's professional services?

Answer 35

Direct charges for a physician's professional services include the fees for the services provided by the physician as well as reasonable overhead expenses incurred in the provision of these services. This can encompass costs associated with maintaining a practice such as salaries rent and supplies.

Question 36

What limitations are placed on the charges for medical-legal reports?

Answer 36

Charges for medical-legal reports may not exceed the direct charges for the physician's professional services. Additionally charges must account for the reasonable costs of laboratory examinations diagnostic studies other medical tests and clerical expenses necessary for producing the report.

Question 37

What are the consequences of failing to comply with the report requirements according to Section f?

Answer 37

Failure to comply with the requirements of the section will render the report inadmissible as evidence. Furthermore it eliminates any liability for payment of medical-legal expenses incurred in connection with the report meaning that non-compliance can have significant financial implications for the physician.

Question 38

What types of inquiries must a physician make when reviewing a patient's medical history?

Answer 38

When reviewing a patient's medical history the physician must make inquiries that are necessary and appropriate to identify relevant medical issues. This may involve asking the patient about their symptoms previous treatments family medical history and any other information that would contribute to a comprehensive understanding of the patient's health.

Question 39

What might be included in 'reasonable costs' of laboratory examinations and diagnostic studies?

Answer 39

Reasonable costs for laboratory examinations and diagnostic studies may include the fees charged for conducting tests (such as blood work or imaging studies) the cost of materials and equipment used during the testing process and any associated professional fees for interpreting the results.

Question 40

Why should physicians ensure their reports comply with legal requirements?

Answer 40

Physicians must ensure their reports comply with legal requirements to maintain their admissibility as evidence in legal situations. Compliance also protects them from financial liability regarding medical-legal expenses ensuring they can manage their professional and legal responsibilities effectively.

Question 41

How does overhead expense relate to direct charges for a physician's services?

Answer 41

Overhead expenses are part of the direct charges for a physician's professional services. They cover the necessary operational costs of running a practice which may include rent utilities salaries of non-medical staff equipment maintenance and other operational costs that support the physician's ability to provide services.

Question 42

What steps can a physician take to ensure compliance with reporting requirements?

Answer 42

A physician can ensure compliance with reporting requirements by thoroughly reviewing patient records conducting necessary examinations documenting all findings accurately understanding legal standards and adhering to guidelines for producing medical reports. Regular training and consultation with legal experts can also aid in maintaining compliance.

Question 43

What is the civil penalty for a physician's failure to comply with the requirements of this section?

Answer 43

The civil penalty for a physician's failure to comply with the requirements of this section is up to one thousand dollars ($1000) for each violation.

Question 44

Who assesses the civil penalties for physicians who violate this section?

Answer 44

Civil penalties are assessed by a workers' compensation judge or the appeals board.

Question 45

Where are the civil penalties collected under this section deposited?

Answer 45

All civil penalties collected under this section are deposited in the Workers' Compensation Administration Revolving Fund.

Question 46

What consequences can a physician face if they are assessed a civil penalty under this section concerning their status as a qualified medical evaluator?

Answer 46

A physician assessed a civil penalty may be terminated suspended or placed on probation as a qualified medical evaluator.

Question 47

What legal consequences can a physician face for knowing failure to comply with this section?

Answer 47

Knowing failure to comply with the requirements of this section can subject the physician to contempt pursuant to the judicial powers vested in the appeals board.

Question 48

What must a person bill for when conducting medical-legal evaluations diagnostic procedures or diagnostic services performed by others?

Answer 48

Any person billing for medical-legal evaluations diagnostic procedures or diagnostic services performed by persons other than those employed by the reporting physician or physicians must specify that those services were performed by others.

Question 49

What are the subdivisions referenced regarding the consequences for a physician assessed a civil penalty?

Answer 49

The subdivisions referenced concerning termination suspension or probation of a physician are k and l of Section 139.2.

Question 50

What does the term 'amount paid' refer to in this context?

Answer 50

The term 'amount paid' refers to the financial compensation given to individuals for evaluations procedures or services performed.

Question 51

What section outlines exceptions to the application of payment for procedures or services?

Answer 51

Section 5307.1 outlines exceptions where the payment provisions do not apply.

Question 52

What declaration must a physician include when signing a report?

Answer 52

The physician must include a declaration stating 'I declare under penalty of perjury that the information contained in this report and its attachments if any is true and correct to the best of my knowledge and belief...'.

Question 53

What is the legal implication of the physician's declaration in the report?

Answer 53

The declaration is made under penalty of perjury meaning that providing false information can lead to legal consequences.

Question 54

What information must a physician's declaration specify if they received it from other sources?

Answer 54

If the physician received information from other sources they must indicate that and declare that the information accurately describes what was provided to them.

Question 55

What additional documentation must the reporting physician provide upon request?

Answer 55

The reporting physician must provide a curriculum vitae upon request.

Question 56

What statement must be included in the physician's curriculum vitae?

Answer 56

The curriculum vitae must include a statement concerning the percent of work performed by the physician related to the case.

Question 57

What details must be included when the physician signs the report?

Answer 57

The report must be dated and signed by the reporting physician and it should also indicate the county in which it was signed.

Question 58

Why is it important for the physician's report to contain truthful information?

Answer 58

It is essential for the integrity of the medical and legal process ensuring that evaluations and procedures are based on accurate and reliable data.

Question 59

What is the consequence if a physician knowingly provides false information in their report?

Answer 59

The physician may face legal penalties for perjury as they are signing a declaration under penalty of perjury.

Question 60

What are the guidelines for the selection of Qualified Medical Evaluators (QMEs) according to the document?

Answer 60

The panels of Qualified Medical Evaluators (QMEs) shall be selected randomly from the appropriate specialty identified by the party who holds the legal right to designate the specialty. Consideration must be given to the proximity of the QME's medical office to the employee's residence.

Question 61

What are the exclusions in the QME panel selection process?

Answer 61

The Medical Director shall exclude any QME who has informed the Medical Director that he or she is unavailable according to section 33 of Title 8 of the California Code of Regulations.

Question 62

Can a physician who has previously treated an employee perform a QME evaluation on that same employee?

Answer 62

No any physician who has served as a primary treating physician or secondary physician and has provided treatment to the employee for the disputed injury shall not perform a QME evaluation on that employee. The physician must disqualify themselves if contacted.

Question 63

What is the legal reference associated with the QME disqualification due to prior treatment?

Answer 63

The disqualification is in accordance with section 9785 of Title 8 of the California Code of Regulations.

Question 64

What must a QME do if their name appears on a panel after having treated the employee?

Answer 64

If a physician's name appears on a QME panel and they have previously treated the employee they must disqualify themselves if contacted.

Question 65

What is the primary function of a Qualified Medical Evaluator (QME)?

Answer 65

The primary function of a Qualified Medical Evaluator (QME) is to provide an independent assessment of the injured employee's medical condition in accordance with workers' compensation laws.

Question 66

How is the QME panel selection process affected by a physician's availability?

Answer 66

If a QME informs the Medical Director of their unavailability pursuant to section 33 of Title 8 of the California Code of Regulations they will be excluded from the selection process for the panel.