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.
