6. QME Availability and Reports Medical legal Expense 4 Flashcards
What should be done if an evaluator determines that another specialty is needed for evaluating medical conditions?
If the evaluator recommends that a new evaluator in another specialty is needed to evaluate one or more disputed medical conditions outside their areas of clinical competence this recommendation should be made clear.
What is a possible scenario in which a new evaluator is needed?
A new evaluator may be needed if the injured worker is unrepresented or if the parties in a represented case cannot agree on an Agreed Medical Evaluator.
What is an Agreed Medical Evaluator (AME)?
An Agreed Medical Evaluator (AME) is a neutral evaluator chosen by the parties involved in a workers’ compensation case to assess medical issues and offer an unbiased opinion.
What is one of the orders that can be given by a Workers’ Compensation Administrative Law Judge in regards to evaluators?
A Workers’ Compensation Administrative Law Judge can order a panel of Qualified Medical Evaluator (QME) physicians and designate a party to select the specialty or specify the specialty to be selected along with the residential or employment zip code for random selection of evaluators.
What process should take place in an unrepresented case to add an additional QME evaluator?
In an unrepresented case the parties must confer with an Information and Assistance Officer and explain the need for an additional QME evaluator.
What is the importance of timely evaluations in workers’ compensation claims?
Timely evaluations are crucial in workers’ compensation claims as they facilitate the resolution of disputes and ensure that injured workers receive appropriate care and compensation.
What factors could influence the selection of a QME?
Factors that could influence the selection of a QME include the specialty required the evaluator’s area of clinical competence the residential or employment-based zip code and the parties’ agreement on a neutral evaluator.
Define ‘Information and Assistance Officer’ within the context of workers’ compensation cases.
An Information and Assistance Officer provides support and information to injured workers and other parties involved in workers’ compensation claims helping them navigate the process and understand their rights.
Why might a worker be unrepresented in a workers’ compensation case?
A worker may be unrepresented due to a lack of resources understanding of the legal process or access to legal representation which can make it challenging for them to navigate their claim.
What impact does an unrepresented worker’s case have on the need for additional evaluation?
If a worker is unrepresented and a need for additional evaluation arises it is essential to ensure they have proper guidance and resources to address their medical and legal needs effectively.
What is the general process for resolving disputed medical issues in workers’ compensation cases?
The general process involves evaluating the disputed medical issues selecting appropriate evaluators (either agreed upon by the parties or designated by a judge) conducting evaluations and addressing any recommendations for additional evaluations as needed.
What is the role of the Information and Assistance Officer in the panel request process?
The Information and Assistance Officer assists the parties in reaching an agreement regarding disputed issues and is involved in the process of requesting an additional Qualified Medical Evaluator (QME) panel.
How can the parties confer with the Information and Assistance Officer?
The parties may confer with the Information and Assistance Officer either in person or by conference call.
What sections of the Labor Code are cited regarding the authority for the procedures mentioned?
The authority cited includes Sections 133 139.2 4061 4062 4062.3 4062.5 5307.3 and 5703.5 of the Labor Code.
Which sections of the Labor Code are referenced in relation to consultations?
The referenced sections include 139.2 4061 4062 4062.1 4062.2 4062.3 4064 and 4067 of the Labor Code.
When was the new section filed and when did it become operative?
The new section was filed on January 13 2009 and became operative on February 17 2009.
What amendments were made to the subsections b1 and b3 and when?
The amendments to subsections b1 and b3 were filed on December 31 2012 as an emergency measure and became operative on January 1 2013.
What will happen if a Certificate of Compliance is not transmitted by July 1 2013?
If a Certificate of Compliance is not transmitted to the Office of Administrative Law (OAL) by July 1 2013 the emergency language will be repealed by operation of law the following day.
What is the importance of Sections 4062.1 and 4067 in the context of consultations?
Sections 4062.1 and 4067 provide further context and guidance regarding medical evaluations and the procedures related to workers’ compensation claims which are relevant during consultations.
What is meant by ‘disputed issues’ in this context?
Disputed issues refer to disagreements between parties involved in a workers’ compensation claim which may require additional evaluation or mediation to resolve.
What does ‘QME’ stand for in the context of this document?
‘QME’ stands for Qualified Medical Evaluator a professional who evaluates the medical aspects of work-related injuries.
What is the role of an acupuncturist in evaluating disability issues according to the provided text?
An acupuncturist selected by an injured worker from a three-member panel is responsible for requesting a consultation from a Qualified Medical Evaluator (QME) to evaluate the disability issues. Additionally the acupuncturist must evaluate all other issues necessary for a complete evaluation.
What must an acupuncturist do if they require a consulting QME for evaluating disability issues?
If the QME acupuncturist requests a QME to provide the consulting evaluation the Medical Director is required to issue a panel within fifteen (15) days of the request in the specialty selected by the QME acupuncturist.
Can a QME obtain a consultation for the purpose of opinions regarding permanent disability and apportionment?
No except as provided in subdivision 32a no QME may obtain a consultation for the purpose of obtaining an opinion regarding permanent disability and apportionment consistent with the requirements of Labor Code sections 4660 through 4664 and the AMA Guides.
What does Labor Code section 4064a allow for injuries occurring on or after January 1 1994?
For injuries occurring on or after January 1 1994 a QME may obtain a consultation from any physician as deemed reasonable and necessary according to Labor Code section 4064a.
What constitutes a complete evaluation by an acupuncturist?
A complete evaluation by an acupuncturist includes the assessment of all issues required alongside the necessary consultations regarding disability issues.
What is the timeframe for the Medical Director to issue a panel after a consult request by a QME acupuncturist?
The Medical Director must issue a panel within fifteen (15) days of the request made by the QME acupuncturist.
Define the term ‘QME’ as used in the context of this document.
QME stands for Qualified Medical Evaluator a physician who has been certified to conduct medical examinations and evaluations related to disability issues.
What are the Labor Code sections relevant to permanent disability and apportionment?
The relevant Labor Code sections concerning permanent disability and apportionment are sections 4660 through 4664.
What role does the AMA Guides play in the evaluation of permanent disability?
The AMA Guides are a set of standards and criteria for assessing permanent disability and evaluations must align with these guidelines in the context of the Labor Code.
Is there any exception for QMEs regarding obtaining consultations for permanent disability evaluations?
Yes there are exceptions provided in subdivision 32a that may allow QMEs to obtain consultations in specific contexts but these details are not delineated in the provided text.
What is the role of a QME in providing consultation?
A Qualified Medical Evaluator (QME) determines that a consultation is necessary and must arrange the consultation appointment if the physician selected is not from the QME panel issued by the Medical Director.
What is the QME Form 110 used for?
The QME Form 110 known as the QME Appointment Notification Form is used by the referring QME to notify the injured employee claims administrator (or employer) and attorneys about the appointment date time and place for the consultation.
What must the consulting physician do after the consultation?
The consulting physician must serve their consulting report to the referring QME.
What is required of the referring QME upon receipt of the consulting physician’s report?
Upon receiving the consulting report the referring QME must review it incorporate it by reference into their medical-legal report and provide comments on the consulting physician’s findings and conclusions in the discussion sections of their report.
What is the regulatory authority governing these procedures?
These procedures are governed by the California Code of Regulations specifically under 8 Cal. Code Regs. 110.
What is required by section 38 of Title 8 of the California Code of Regulations regarding medical-legal reports?
A comprehensive medical-legal report must be generated within the time periods specified in section 38 of Title 8 of the California Code of Regulations.
What should be done if a consulting physician’s report is not received on time?
If a consulting physician’s report has not been received or will not be received in time to comply with the specified periods the referring QME must serve the comprehensive medical-legal report timely.
What is the timeframe for a referring evaluator to issue a supplemental report after receiving a consulting physician’s report?
The referring evaluator shall issue a supplemental report within fifteen (15) calendar days of receipt of the consulting report.
What should the supplemental report include regarding the consulting physician’s report?
The supplemental report should incorporate the consulting physician’s report by reference and comment on whether and how the findings in the consulting report change the referring evaluator’s opinions.
What details must the referring evaluator list in the report commenting on a consulting physician’s report?
The referring evaluator must list all reports and information received from each party for the consulting physician indicate whether each item was forwarded to the consulting physician and provide the reasons for any items not forwarded.
What is the consequence of not complying with the timeframes set for medical-legal reports?
Non-compliance with the timeframes may result in delays in the evaluation process and could affect the outcomes of the medical-legal review.
Who is responsible for ensuring the timely submission of a comprehensive medical-legal report?
The referring Qualified Medical Evaluator (QME) is responsible for the timely submission of the comprehensive medical-legal report.
How does the referring evaluator reference the consulting report in their supplemental report?
The referring evaluator incorporates the consulting physician’s report by reference in the supplemental report.
What should the referring evaluator comment on in relation to the consulting physician’s findings?
The referring evaluator should comment on whether and how the findings in the consulting report change their previous opinions.
What important documentation step is required for items not forwarded to the consulting physician?
The referring evaluator must provide the reason for items that were not forwarded to the consulting physician in the report.
What did the referring evaluator determine regarding the need to forward the item to the consulting physician?
The referring evaluator determined that it was not necessary to forward the item to the consulting physician.
What is the exception regarding verbal communications between an injured worker and the consulting physician?
The exception is that verbal communications between an injured worker and the consulting physician are allowed during the course of the consulting examination.
Who is responsible for making all other communications reports and information available to the consulting physician?
All other communications by the parties along with any reports and information for the consulting physician shall be made in writing and directed only to the referring Qualified Medical Evaluator (QME).
What role does the referring QME play in the communication process with the consulting physician?
The referring QME may forward the written communications and reports to the consulting physician as appropriate.
Is direct communication allowed between the parties or their attorneys and the consulting physician?
No neither party nor a party’s attorney shall communicate directly with nor send correspondence or records directly to the consulting physician with the exception of deposing the consulting physician if necessary.
Where can the form mentioned in the text be obtained?
The form can be obtained at no charge by downloading it from the web at www.dir.ca.gov/dwc/forms.html or by requesting it at 1-800-794-6900.
What authority is cited in the text provided?
The authority cited includes Sections 133 139.2 4061 4062 and 4064.
What is the importance of written communication in the process described?
Written communication is essential as it ensures proper documentation and maintains a formal channel for sharing information between parties and the consulting physician.
What could be a potential consequence if parties directly contacted the consulting physician without following the designated communication protocol?
Potential consequences could include miscommunication the undermining of the process or issues regarding the validity of the workers’ compensation claims.
What types of documents might be included in the communications directed to the referring QME?
Documents may include medical reports letters summarizing case details and any other relevant written information that would assist the consulting physician in understanding the case.
What is the reference provided in the Labor Code sections mentioned for this document?
The reference provided in the Labor Code includes Sections 3209.3 4061 4062 4062.1 4062.2 4064 4067 and 5703.5.
What is the importance of the section filed on 8-1-94 and its operative date?
The section filed on 8-1-94 became operative on 8-31-94 marking a significant update in the Labor Code with new regulatory guidelines.
What happened to the former section 32 and section 32.5 in April 2000?
In April 2000 the former section 32 was renumbered to section 30.5 and the former section 32.5 was renumbered and amended to section 32.
What was the operative date for the renumbering and amendment in April 2000?
The operative date for the renumbering and amendment in April 2000 was 5-14-2000.
When was a new section filed on 8-23-96 and what was its operative date?
A new section was filed on 8-23-96 and it became operative on 9-22-96.
What is the authority cited for the amendments in sections 32 and 32.5?
The authority cited for the amendments in sections 32 and 32.5 includes Sections 139.2 4061 4062 and 4064 of the Labor Code.
What occurred regarding section 32.6 concerning QME evaluations?
Section 32.6 pertains to additional QME evaluations that may be ordered by appeals indicating further procedural guidance in the Labor Code.
What was the operative date for the repealer filed on 1-13-2009?
The operative date for the repealer filed on 1-13-2009 was 2-17-2009.
