6. QME Availability and Reports Medical legal Expense 2

Question 1

What is the significance of the QME’s proximity to the employee’s home?

Answer 1

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.

Question 2

What happens if a physician has also served as a treating physician for the disputed injury?

Answer 2

The physician will be disqualified from performing a QME evaluation on the employee they have treated for that disputed injury.

Question 3

Which section of the California Code of Regulations outlines the rules for QME evaluations?

Answer 3

The rules for QME evaluations are outlined in Title 8 specifically section 9785 and section 33.

Question 4

What is the role of a Qualified Medical Evaluator (QME) in California Workers’ Compensation?

Answer 4

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.

Question 5

Under what circumstances can either party request a replacement QME?

Answer 5

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.

Question 6

What is the minimum number of active QMEs required in a specialty to issue a panel for selection?

Answer 6

There must be at least five active QMEs in the selected specialty at the time the panel selection is requested.

Question 7

What happens if there are fewer than five active QMEs in the requested specialty?

Answer 7

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.

Question 8

What are the authority and reference sections cited for the rules regarding Qualified Medical Evaluators?

Answer 8

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.

Question 9

When was the new section regarding QMEs filed and when did it become operative?

Answer 9

The new section was filed on August 1 1994 and became operative on August 31 1994.

Question 10

What significant changes were made to the QME regulations on April 14 2000?

Answer 10

On April 14 2000 there was an amendment of subsections b and d related to Qualified Medical Evaluators.

Question 11

What is the purpose of having a panel of QMEs?

Answer 11

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.

Question 12

What is the date when the amendment of section and note was filed?

Answer 12

The amendment of section and note was filed on January 13 2009.

Question 13

When did the amendment become operative?

Answer 13

The amendment became operative on February 17 2009.

Question 14

What is the regulation concerned with in the provided text?

Answer 14

The regulation concerns QME (Qualified Medical Evaluator) Panel Selection Disputes in Represented Cases.

Question 15

What happens when the Medical Director receives two or more QME panel selection forms on the same day with different physician specialties?

Answer 15

The Medical Director will follow specific procedures to resolve the dispute regarding panel selections.

Question 16

If one party requests the same specialty as that of the treating physician what action does the Medical Director take?

Answer 16

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.

Question 17

What if no party requests a panel in the specialty of the treating physician?

Answer 17

The Medical Director shall select a specialty appropriate for the medical issue in dispute and issue a panel in that specialty.

Question 18

What does the Medical Director require from the party requesting a different specialty panel?

Answer 18

Upon request the Medical Director may ask for supporting documentation to justify the requested specialty.

Question 19

What is the role of the Medical Director when provided with additional medical records in the context of determining a QME specialty?

Answer 19

The Medical Director uses the additional medical records to assist in determining the appropriate specialty for the Qualified Medical Evaluator (QME) panel.

Question 20

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?

Answer 20

The party must submit relevant documentation supporting the reason for requesting a different specialty along with the panel request form.

Question 21

What is the time frame within which the Medical Director must issue a QME panel in a represented case?

Answer 21

The Medical Director must issue a QME panel within thirty (30) calendar days of receiving the request.

Question 22

What options do parties have if the Medical Director cannot issue a QME panel within the specified time frame?

Answer 22

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.

Question 23

Which sections of the Labor Code are cited as authority for the requirements regarding the QME panel request?

Answer 23

Sections cited include 133 139.2 and 5307.3.

Question 24

Which specific sections of the Labor Code are referenced in relation to the QME panel and its specialty?

Answer 24

The referenced sections are 4060 4061 4062 4062.2 4064 and 4067.

Question 25

When was the new section regarding the QME panel and related processes filed?

Answer 25

The new section was filed on January 13 2009.

Question 26

What is a QME panel in the context of Labor Code section 4062.2?

Answer 26

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.

Question 27

What information should be included with the panel request form when seeking a QME panel in a different specialty?

Answer 27

The request should include any relevant documentation that supports the reason for requesting a different specialty.

Question 28

What happens if a party fails to provide relevant documentation when requesting a different specialty for a QME panel?

Answer 28

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.

Question 29

What is the date of the operative for the QME Office Locations regulation?

Answer 29

February 17 2009.

Question 30

What should a Qualified Medical Evaluator (QME) notify the Medical Director of as of January 1 2013?

Answer 30

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.

Question 31

During what time frame is a QME's office location not allowed to be substituted for another location?

Answer 31

Between January 1 2013 and July 1 2013.

Question 32

What must a QME show to substitute an office location during the restricted time frame?

Answer 32

A QME must show 'good cause' to the Medical Director.

Question 33

What are some examples of 'good cause' for changing an office location?

Answer 33

Good cause includes but is not limited to natural disasters or other community catastrophes that interrupt the operation of the evaluator's business.

Question 34

What authority is cited for the QME Office Locations regulation?

Answer 34

Sections 133 139.2 and 5307.3 of the Labor Code.

Question 35

List some of the references mentioned in the QME Office Locations section of the Labor Code.

Answer 35

Sections 139.2 4060 4061 4062 4062.1 4062.2 4062.5 and 4067.

Question 36

When was the new section regarding QME Office Locations filed?

Answer 36

December 31 2012.

Question 37

What does the term 'QME' stand for?

Answer 37

Qualified Medical Evaluator.

Question 38

What legislation governs the emergency operative for the new QME Office Locations section?

Answer 38

Government Code section 11346.1d.

Question 39

What is the effective date of the newly filed QME section regarding office locations?

Answer 39

January 1 2013.

Question 40

What was the prior history reference for this regulation?

Answer 40

Register 2000 No. 15.

Question 41

What must be transmitted to OAL by July 1 2013 according to Register 2013 No. 1?

Answer 41

A Certificate of Compliance.

Question 42

What happens if the Certificate of Compliance is not transmitted by July 1 2013?

Answer 42

Emergency language will be repealed by operation of law on the following day.

Question 43

For prior history regarding the Certificate of Compliance which register should be referenced?

Answer 43

Register 2000 No. 15.

Question 44

What is the time frame for an unrepresented employee to select a QME after receiving the form?

Answer 44

Within ten (10) days of having been furnished with the form.

Question 45

What should an unrepresented employee do to schedule an appointment with a QME after selecting one?

Answer 45

Contact the QME to schedule an appointment and inform the claims administrator of the QME selection and the appointment.

Question 46

Who is prohibited from discussing the selection of the QME with an unrepresented worker?

Answer 46

Neither the employer nor the claims administrator nor any other representative of the employer.

Question 47

What must an unrepresented employee do within ten (10) days of the issuance of a QME panel?

Answer 47

Select a QME from the QME panel and schedule an appointment with the selected QME.

Question 48

What may the claims administrator do if the unrepresented employee fails to select a QME or schedule an appointment within ten (10) days?

Answer 48

The claims administrator may take further action as permitted under the law or regulations.

Question 49

What is the purpose of Labor Code section 4062.1c?

Answer 49

Labor Code section 4062.1c outlines the process for scheduling an appointment with a Qualified Medical Evaluator (QME) for employees in workers' compensation cases.

Question 50

Who is responsible for notifying the employee about the QME appointment?

Answer 50

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.

Question 51

What must happen before a represented employee can schedule an appointment with a QME?

Answer 51

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.

Question 52

How long does a represented employee have to schedule an appointment with the selected QME?

Answer 52

A represented employee has ten (10) business days from the date a QME is selected from the panel to schedule the appointment.

Question 53

What happens if the represented employee fails to schedule the appointment within the specified timeframe?

Answer 53

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.

Question 54

What sections of the Labor Code are cited as authority for these appointment scheduling rules?

Answer 54

The authority cited includes Sections 133 139.2 and 5307.3 of the Labor Code.

Question 55

Which sections of the Labor Code reference QME procedures?

Answer 55

The sections that reference QME procedures are 4060 4061 4062 4062.1 4062.2 4064 and 4067.

Question 56

When was the new section regarding QME appointment scheduling filed?

Answer 56

The new section regarding QME appointment scheduling was filed on January 13 2009.

Question 57

When did the new section become operative?

Answer 57

The new section became operative on February 17 2009.

Question 58

What is a QME replacement request?

Answer 58

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.

Question 59

What does QME stand for in the context of medical evaluations?

Answer 59

QME stands for Qualified Medical Evaluator a physician who has been certified to evaluate individuals for the purposes of workers' compensation.

Question 60

Under what circumstances can the Medical Director replace an entire panel of QMEs?

Answer 60

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.

Question 61

How long does a QME have to schedule an examination after the initial request for an appointment?

Answer 61

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.

Question 62

What is the relevance of section 33e of Title 8 of the California Code of Regulations?

Answer 62

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.

Question 63

What does the term 'same group practice' refer to in the context of QMEs?

Answer 63

'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.

Question 64

What is the protocol for the Medical Director if a QME cannot schedule an exam within the required time frame?

Answer 64

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.

Question 65

What happens if the injured worker’s residence changes after a QME panel is issued?

Answer 65

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.