6. QME Availability and Reports Medical legal Expense 2 Flashcards
What is the significance of the QME’s proximity to the employee’s home?
The proximity of the QME’s medical office to the employee’s residence is taken into consideration to ensure that the evaluation is accessible to the employee.
What happens if a physician has also served as a treating physician for the disputed injury?
The physician will be disqualified from performing a QME evaluation on the employee they have treated for that disputed injury.
Which section of the California Code of Regulations outlines the rules for QME evaluations?
The rules for QME evaluations are outlined in Title 8 specifically section 9785 and section 33.
What is the role of a Qualified Medical Evaluator (QME) in California Workers’ Compensation?
A Qualified Medical Evaluator (QME) is responsible for conducting medical evaluations in workers’ compensation cases to assess the extent of an injured worker’s injuries determine the level of disability and provide opinions on treatment and care.
Under what circumstances can either party request a replacement QME?
Either party may request a replacement QME if they believe that the current QME is unable to perform the evaluation due to reasons such as bias unqualified status or unavailability. This request can be made pursuant to section 31.5 of Title 8 of the California Code of Regulations.
What is the minimum number of active QMEs required in a specialty to issue a panel for selection?
There must be at least five active QMEs in the selected specialty at the time the panel selection is requested.
What happens if there are fewer than five active QMEs in the requested specialty?
If there are less than five active QMEs in the requested specialty the Medical Director is required to contact the party who has the legal right to designate the specialty for an alternate specialty selection.
What are the authority and reference sections cited for the rules regarding Qualified Medical Evaluators?
The authority cited for these rules includes Sections 133 139.2 4061 4062 and 5307.3 of the Labor Code. The reference sections include Sections 139.2 4060 4061 4062 4062.1 4062.2 4064 and 4067 of the Labor Code.
When was the new section regarding QMEs filed and when did it become operative?
The new section was filed on August 1 1994 and became operative on August 31 1994.
What significant changes were made to the QME regulations on April 14 2000?
On April 14 2000 there was an amendment of subsections b and d related to Qualified Medical Evaluators.
What is the purpose of having a panel of QMEs?
The purpose of having a panel of QMEs is to ensure that injured workers have access to qualified medical experts who can provide impartial and expert evaluations regarding their medical conditions and work-related injuries.
What is the date when the amendment of section and note was filed?
The amendment of section and note was filed on January 13 2009.
When did the amendment become operative?
The amendment became operative on February 17 2009.
What is the regulation concerned with in the provided text?
The regulation concerns QME (Qualified Medical Evaluator) Panel Selection Disputes in Represented Cases.
What happens when the Medical Director receives two or more QME panel selection forms on the same day with different physician specialties?
The Medical Director will follow specific procedures to resolve the dispute regarding panel selections.
If one party requests the same specialty as that of the treating physician what action does the Medical Director take?
The panel shall be issued in the specialty of the treating physician unless the Medical Director is convinced otherwise by supporting documentation provided by the requestor.
What if no party requests a panel in the specialty of the treating physician?
The Medical Director shall select a specialty appropriate for the medical issue in dispute and issue a panel in that specialty.
What does the Medical Director require from the party requesting a different specialty panel?
Upon request the Medical Director may ask for supporting documentation to justify the requested specialty.
What is the role of the Medical Director when provided with additional medical records in the context of determining a QME specialty?
The Medical Director uses the additional medical records to assist in determining the appropriate specialty for the Qualified Medical Evaluator (QME) panel.
What must a party do if they request a QME panel in a specialty different from the treating physician’s specialty under Labor Code section 4062.2?
The party must submit relevant documentation supporting the reason for requesting a different specialty along with the panel request form.
What is the time frame within which the Medical Director must issue a QME panel in a represented case?
The Medical Director must issue a QME panel within thirty (30) calendar days of receiving the request.
What options do parties have if the Medical Director cannot issue a QME panel within the specified time frame?
Either party may seek an order from a Workers’ Compensation Administrative Law Judge to issue a QME panel. The order must specify the specialty of the QME panel or who is designated to select the specialty.
Which sections of the Labor Code are cited as authority for the requirements regarding the QME panel request?
Sections cited include 133 139.2 and 5307.3.
Which specific sections of the Labor Code are referenced in relation to the QME panel and its specialty?
The referenced sections are 4060 4061 4062 4062.2 4064 and 4067.
When was the new section regarding the QME panel and related processes filed?
The new section was filed on January 13 2009.
What is a QME panel in the context of Labor Code section 4062.2?
A Qualified Medical Evaluator (QME) panel is a group of qualified professionals appointed to evaluate and provide opinions on medical issues related to workers’ compensation cases.
What information should be included with the panel request form when seeking a QME panel in a different specialty?
The request should include any relevant documentation that supports the reason for requesting a different specialty.
What happens if a party fails to provide relevant documentation when requesting a different specialty for a QME panel?
The request may be insufficient and the Medical Director may not be able to make an informed decision on the specialty for the QME panel.
What is the date of the operative for the QME Office Locations regulation?
February 17 2009.
What should a Qualified Medical Evaluator (QME) notify the Medical Director of as of January 1 2013?
A QME shall notify the Medical Director of the street address of the 10 or fewer office locations where the QME will conduct qualified medical evaluations.
During what time frame is a QME’s office location not allowed to be substituted for another location?
Between January 1 2013 and July 1 2013.
What must a QME show to substitute an office location during the restricted time frame?
A QME must show ‘good cause’ to the Medical Director.
What are some examples of ‘good cause’ for changing an office location?
Good cause includes but is not limited to natural disasters or other community catastrophes that interrupt the operation of the evaluator’s business.
What authority is cited for the QME Office Locations regulation?
Sections 133 139.2 and 5307.3 of the Labor Code.
List some of the references mentioned in the QME Office Locations section of the Labor Code.
Sections 139.2 4060 4061 4062 4062.1 4062.2 4062.5 and 4067.
When was the new section regarding QME Office Locations filed?
December 31 2012.
What does the term ‘QME’ stand for?
Qualified Medical Evaluator.
What legislation governs the emergency operative for the new QME Office Locations section?
Government Code section 11346.1d.
What is the effective date of the newly filed QME section regarding office locations?
January 1 2013.
What was the prior history reference for this regulation?
Register 2000 No. 15.
What must be transmitted to OAL by July 1 2013 according to Register 2013 No. 1?
A Certificate of Compliance.
What happens if the Certificate of Compliance is not transmitted by July 1 2013?
Emergency language will be repealed by operation of law on the following day.
For prior history regarding the Certificate of Compliance which register should be referenced?
Register 2000 No. 15.
What is the time frame for an unrepresented employee to select a QME after receiving the form?
Within ten (10) days of having been furnished with the form.
What should an unrepresented employee do to schedule an appointment with a QME after selecting one?
Contact the QME to schedule an appointment and inform the claims administrator of the QME selection and the appointment.
Who is prohibited from discussing the selection of the QME with an unrepresented worker?
Neither the employer nor the claims administrator nor any other representative of the employer.
What must an unrepresented employee do within ten (10) days of the issuance of a QME panel?
Select a QME from the QME panel and schedule an appointment with the selected QME.
What may the claims administrator do if the unrepresented employee fails to select a QME or schedule an appointment within ten (10) days?
The claims administrator may take further action as permitted under the law or regulations.
What is the purpose of Labor Code section 4062.1c?
Labor Code section 4062.1c outlines the process for scheduling an appointment with a Qualified Medical Evaluator (QME) for employees in workers’ compensation cases.
Who is responsible for notifying the employee about the QME appointment?
The party responsible for notifying the employee about the appointment is the claims administrator or administrator’s attorney if the employee does not schedule the appointment within the specified timeframe.
What must happen before a represented employee can schedule an appointment with a QME?
Before a represented employee can schedule an appointment with a QME the parties must complete the conferring and striking processes as described in Labor Code section 4062.2c.
How long does a represented employee have to schedule an appointment with the selected QME?
A represented employee has ten (10) business days from the date a QME is selected from the panel to schedule the appointment.
What happens if the represented employee fails to schedule the appointment within the specified timeframe?
If the represented employee fails to schedule the appointment within ten (10) business days the claims administrator or administrator’s attorney may arrange the appointment and provide notification to both the employee and the employee’s attorney.
What sections of the Labor Code are cited as authority for these appointment scheduling rules?
The authority cited includes Sections 133 139.2 and 5307.3 of the Labor Code.
Which sections of the Labor Code reference QME procedures?
The sections that reference QME procedures are 4060 4061 4062 4062.1 4062.2 4064 and 4067.
When was the new section regarding QME appointment scheduling filed?
The new section regarding QME appointment scheduling was filed on January 13 2009.
When did the new section become operative?
The new section became operative on February 17 2009.
What is a QME replacement request?
A QME replacement request is a request for a new QME to be assigned to a panel when a previously selected QME is unavailable or deemed inappropriate for the case.
What does QME stand for in the context of medical evaluations?
QME stands for Qualified Medical Evaluator a physician who has been certified to evaluate individuals for the purposes of workers’ compensation.
Under what circumstances can the Medical Director replace an entire panel of QMEs?
The Medical Director can replace an entire panel of QMEs if any of the following occurs: 1) A QME does not practice in the specialty requested 2) A QME cannot schedule an examination within 60 days (or 90 days if the scheduling limit has been waived) 3) The injured worker changes residence since the panel was issued or 4) A physician on the panel is in the same group practice as another QME on the panel.
How long does a QME have to schedule an examination after the initial request for an appointment?
A QME must schedule an examination within 60 days of the initial request for an appointment. If the scheduling limit has been waived under section 33e of Title 8 the examination must be scheduled within 90 days.
What is the relevance of section 33e of Title 8 of the California Code of Regulations?
Section 33e of Title 8 of the California Code of Regulations provides the conditions under which the 60-day scheduling limit for a QME can be waived allowing for a 90-day period instead.
What does the term ‘same group practice’ refer to in the context of QMEs?
‘Same group practice’ refers to a situation where two or more physicians are part of the same professional practice group or organization which can affect the selection of QMEs due to potential conflicts of interest.
What is the protocol for the Medical Director if a QME cannot schedule an exam within the required time frame?
If a QME cannot schedule an exam within the required time frame the Medical Director shall replace the entire panel of QMEs and select a new panel at random.
What happens if the injured worker’s residence changes after a QME panel is issued?
If an injured worker changes their residence after a QME panel is issued this may be grounds for the Medical Director to replace the panel of QMEs.
