6. QME Availability and Reports Medical legal Expense 3 Flashcards
What is the significance of the party holding the legal right to request the panel?
The party holding the legal right to request the QME panel is typically a stakeholder in the workers’ compensation claim process (e.g. the injured worker or the employer) and their specified specialty needs must be met by the QMEs on the panel.
What might be a potential consequence of having multiple QMEs from the same group practice?
Having multiple QMEs from the same group practice may create a conflict of interest as the opinions of the QMEs may be influenced by their shared professional affiliations which could bias the evaluations.
In the event of replacing a QME panel how is the replacement conducted?
The replacement of the QME panel is conducted by the Medical Director selecting QMEs at random from the list of qualified evaluators.
What conditions allow for the unavailability of a Qualified Medical Evaluator (QME) according to the section 33?
A QME is considered unavailable under section 33 if: 1) The QME is unable to fulfill their duties; 2) The evaluator who previously reported on the case is no longer available; 3) A QME named on the panel has been the employee’s primary treating physician or secondary physician for the injury in dispute.
What is required for a new QME panel to be issued at the employee’s request?
For a new QME panel to be issued at the employee’s request the claims administrator (or the employer if there is none) and the employee must agree in writing that a new panel may be issued for the employee’s convenience. A copy of this agreement must be submitted with the panel replacement request.
Who has the authority to replace a QME and under what conditions?
The Medical Director has the authority to replace a QME or a panel upon written request if they find good cause for the replacement. Good cause is defined as documented medical or psychological impairment related to the nature of the injury.
What documentation supports the definition of ‘good cause’ regarding the replacement of a QME?
Good cause for the replacement of a QME is supported by documented medical or psychological impairment.
Can an employee’s convenience justify a new panel and if so how?
Yes an employee’s convenience can justify a new QME panel if both the claims administrator (or employer) and the employee agree in writing to issue a new panel in the geographic area of the employee’s workplace.
What is section 9785 of Title 8 of the California Code of Regulations related to?
Section 9785 of Title 8 of the California Code of Regulations pertains to the circumstances under which a physician can serve as a primary treating physician or secondary physician in relation to a worker’s compensation injury.
Describe what a QME is and its role in the workers’ compensation process.
A Qualified Medical Evaluator (QME) is a physician who is certified and authorized to perform independent medical evaluations as part of the workers’ compensation process. The QME assesses the medical aspects of a work-related injury to help determine the extent of injuries treatment needs and compensability.
What steps should be taken if a QME stated in the panel is the employee’s treating physician?
If a QME listed in the panel is currently or has been the employee’s treating physician the employee or other involved parties should consider requesting a replacement panel or QME to avoid conflicts of interest and ensure an impartial evaluation.
In the context of QME unavailability what happens if both the employer and employee do not agree on a new panel?
If the employer and employee do not agree on a new panel the process outlined for replacing a QME must still be followed which could involve the Medical Director’s involvement or identifying a valid reason as outlined in the regulations.
What form must be filed upon written request to the Director for an Occupational Injury or Illness Report?
The Doctor’s First Report of Occupational Injury or Illness Form DLSR 5021 must be filed upon written request.
Which California Code of Regulations sections relate to the filing of the Doctor’s First Report of Occupational Injury or Illness?
8 Cal. Code Regs. 14006 and 14007 relate to the filing of the Doctor’s First Report of Occupational Injury or Illness.
What is the DWC Form PR-2?
DWC Form PR-2 is the ‘Primary Treating Physician’s Progress Report’ required for tracking the medical progress of an injured employee.
Which California Code of Regulations section pertains to the Primary Treating Physician’s Progress Report?
8 Cal. Code Regs. 9785.2 pertains to the Primary Treating Physician’s Progress Report.
What action can the Medical Director take after reviewing appropriate records regarding a specialty designation?
The Medical Director may determine that the chosen specialty is medically or otherwise inappropriate for the disputed medical issues.
What additional actions can the Medical Director request from the parties involved?
The Medical Director may request either party to provide additional information or records necessary for the determination.
What is the significance of section 34 Appointment Notification and Cancellation of Title 8 of the California Code of Regulations?
Section 34 outlines the necessary procedures for appointment notifications and cancellations ensuring proper communication and scheduling.
Under what condition can an evaluator not be replaced after a violation of section 34?
An evaluator will not be replaced if the request for replacement by a party is made more than fifteen (15) calendar days from the date the party became aware of the evaluator’s violation.
What types of information might be deemed ‘medically or otherwise inappropriate’ concerning a specialty designation?
Information that does not align with the disputed medical issues or is inconsistent with accepted medical practices for the injury or illness may be considered inappropriate.
In the context of California’s workers’ compensation regulations why is it important to have accurate and timely reporting of occupational injuries?
Accurate and timely reporting ensures that injured workers receive appropriate medical treatment facilitates efficient claims processing and helps in the evaluation of effectiveness of treatment methods.
What is the purpose of the Doctor’s First Report of Occupational Injury or Illness Form?
The purpose of the Doctor’s First Report is to document the initial evaluation and diagnosis of an injured worker serving as a basis for treatment and claims related to the injury.
What are the potential consequences of failing to comply with the specified filing regulations for occupational injuries in California?
Consequences can include delays in treatment for injured workers potential denial of claims or administrative penalties for the parties involved.
Who holds the legal right to designate a specialty for a medical evaluation in occupational injury cases?
The party holding the legal right to designate a specialty is typically determined by the workers’ compensation insurance policy and applicable regulations.
What is Section 34 of Title 8 of the California Code of Regulations about?
Section 34 deals with the timeline for the submission of reports by evaluators in relation to workers’ compensation claims. It stipulates that reports must be served within specific time frames established by the labor codes.
What happens if an evaluator fails to meet the deadlines specified in Labor Code Section 4062.5?
If an evaluator fails to meet the deadlines specified in Labor Code Section 4062.5 it can lead to objections by the party requesting a replacement on the grounds of lateness and the party must attach a copy of their objection when requesting a replacement.
What must a party do if they object to the timeliness of a medical evaluator’s report?
A party objecting to the timeliness of a medical evaluator’s report must attach a copy of their objection to the request for a replacement.
What is a disqualifying conflict of interest as defined in Section 41.5 of Title 8 of the California Code of Regulations?
A disqualifying conflict of interest refers to situations where the qualified medical evaluator (QME) has personal or financial interests that may bias their evaluation or report rendering them unfit to conduct the evaluation.
What authority does the Administrative Director have under Section 10164c of Title 8 of the California Code of Regulations?
The Administrative Director has the authority to issue orders for additional QME evaluations when necessary to ensure compliance with regulations and to address any potential inadequacies in prior evaluations.
What should be included when a request for a replacement evaluator is made due to lateness of the report?
The request must include a copy of the party’s written objection to the untimely report along with the request for a replacement evaluator.
What is the significance of meeting the deadlines specified in Section 4062.5 of the Labor Code?
Meeting the deadlines is crucial as they ensure that the evaluation process is timely facilitates the required medical assessments for claims and upholds the rights of the involved parties in the workers’ compensation claim process.
What is the role of a Qualified Medical Evaluator (QME) in this context?
The role of a Qualified Medical Evaluator (QME) is to conduct impartial medical evaluations for the purposes of workers’ compensation claims to determine the injured worker’s medical condition and necessary treatment.
What are the conditions under which a Medical Evaluator (QME) refuses to provide a complete medical evaluation or written statement?
A QME may refuse to provide a complete medical evaluation or a written statement if they are not medically qualified or competent to address one or more issues in dispute and they must explain their reasoning in writing upon request.
What is the significance of Labor Code sections 4062.3i and 4062.3j in relation to QMEs?
Labor Code sections 4062.3i and 4062.3j provide the framework for medical evaluations conducted by QMEs and outline the procedures and requirements for such evaluations to ensure they are complete and medically sound.
What time limit is established for requesting a QME replacement or QME panel replacement?
A request for a QME replacement or QME panel replacement must be made within 24 months from the date the QME panel list was issued. If this period has expired the request may be deemed invalid.
What is the process for an unrepresented employee to select a QME?
An unrepresented employee has a specific time limit under Labor Code section 4062.1c to select a QME and schedule an appointment after the notification of a valid replacement request by the Medical Director.
What actions are allowed for a represented employee regarding the QME panel?
A represented employee has the right to strike a name from the QME panel as per the guidelines set forth in applicable Labor Code provisions.
What happens when none of the QMEs on the panel list have examined the injured worker?
If none of the QMEs on the panel list have examined the injured worker the Medical Director may consider a request for a replacement valid provided all other criteria are met.
What is the role of the Medical Director in the process described?
The Medical Director is responsible for determining the validity of requests for QME or QME panel replacements and ensuring that the time limits for selection or strikes are adhered to.
Explain the importance of a QME being competent to address disputed medical issues.
A QME must be competent to ensure the medical evaluation accurately addresses the specific disputes in the case providing valid and credible assessments essential for the resolution of the case.
What steps must a QME take if they believe they are not competent to address issues in a case?
The QME must provide a written statement explaining their lack of competence or qualification to address the disputed medical issues when requested by a party or the Medical Director.
What is the impact of the 24-month limitation on the issuance of the QME panel list on workers’ compensation claims?
This 24-month limitation ensures that evaluations and any necessary replacements are done in a timely manner which is crucial for the efficient processing of workers’ compensation claims.
What happens to the tolling period described in section 4062.2c?
The tolling period shall be tolled until the date the replacement Qualified Medical Evaluator (QME) name or QME panel is issued.
What is the consequence if parties have struck two QME names from a panel and a valid ground arises to replace the remaining QME?
None of the QMEs whose names appeared on the earlier QME panel shall be included in the replacement QME panel.
What sections of the Labor Code are cited as authority for this regulation?
Sections 133 139.2 4061 4062 4062.3 4062.5 5307.3 and 5703.5.
Which sections of the Labor Code are referenced in the text?
Sections referenced include 139.2 4060 4061 4062 4062.1 4062.2 4062.3 4064 and 4067.
When was the new section filed and when did it become operative?
The new section was filed on 8-23-96 and became operative on 9-22-96.
What amendments were made to the subsections in 2000 and when did they become operative?
Amendments of subsections b b1 b3 and the addition of new subsections b45 were filed on 4-14-2000 and became operative on 5-14-2000.
What changes were made to the section and the Note in 2009?
A general amendment of the section and Note was filed on 1-13-2009 and became operative on 2-17-2009.
What does section 31.7 refer to in the context of QMEs?
Section 31.7 discusses obtaining an additional QME panel in a different specialty.
What is an Agreed Medical Evaluator (AME)?
An Agreed Medical Evaluator is a physician mutually agreed upon by the parties involved in a workers’ compensation case to evaluate an injured worker’s medical condition.
What is a Panel QME?
A Panel QME or Panel Qualified Medical Evaluator is a medical professional selected to provide evaluations in workers’ compensation cases specifically to assess medical issues and provide formal medical-legal reports.
What should parties do when a new medical dispute arises after a comprehensive medical-legal report is issued by a Panel QME?
The parties should to the extent possible obtain a follow-up evaluation or a supplemental evaluation from the same Panel QME who issued the initial report.
What constitutes ‘good cause’ for requesting a different specialty Panel QME?
Good cause means: 1) A written agreement by the parties in a represented case that there is a need for an additional comprehensive medical legal report by an evaluator in a different specialty which they have mutually agreed upon or 2) The AME or QME selected advises the parties and the Medical Director or his or her designee that a different specialty is needed.
What happens if good cause is established for a different specialty evaluation?
If good cause is shown the Medical Director shall issue an additional panel of QME physicians selected at random in the requested specialty.
What are the roles of the AME or QME in establishing good cause for a new medical specialty panel?
The AME (Agreed Medical Evaluator) or QME must notify the parties and the Medical Director or designated representative that the case requires a different specialty to resolve disputed medical issues.
What is the significance of a comprehensive medical legal report by a Panel QME?
The comprehensive medical legal report is crucial as it serves as formal documentation of medical assessments in disputes related to workers’ compensation influencing the resolution of the case.
What should parties consider when negotiating the need for an additional comprehensive medical legal report?
They should consider the necessity of expertise in a different medical specialty to effectively address and resolve disputed medical issues inherent in the case.
Define ‘supplemental evaluation’ in the context of a medical dispute.
A supplemental evaluation refers to an additional review or assessment conducted by the same Panel QME aimed at addressing new or unresolved medical disputes that have arisen following their initial report.
What is the procedure for selecting a new Panel QME if needed?
If a different specialty is deemed necessary and good cause is established the Medical Director will randomly select new Panel QME physicians from the specified specialty to evaluate the case.
What is the role of an evaluator in the context of disputed medical issues?
An evaluator must complete a timely evaluation of the disputed medical issues within their scope of practice and areas of clinical competence.
