6. QME Availability and Reports Medical legal Expense 6 Flashcards
What is the process for a QME to notify about a comprehensive medical evaluation appointment?
The QME shall complete an appointment notification form as per Section 110 QME Appointment Notification Form according to 8 Cal. Code Regs. 110. The completed form must be postmarked or sent by facsimile to the employee and claims administrator (or employer if no claims administrator exists) within 5 business days of scheduling the appointment.
What additional step must a QME take in represented cases when notifying about a comprehensive medical evaluation appointment?
In represented cases a copy of the completed notification form must also be sent to the attorney representing each party if known.
What are the consequences of failing to comply with QME notification requirements?
Failing to comply with the notification requirement constitutes grounds for denial of reappointment under Section 51 of Title 8 of the California Code of Regulations.
Where should the comprehensive medical-legal examination be conducted according to the QME regulations?
The comprehensive medical-legal examination must be conducted at the medical office listed on the panel selection form.
Can an injured worker request a different evaluation appointment for convenience?
Yes an injured worker can request a different evaluation appointment for their convenience; however this request must be made in writing.
What is a QME?
A QME or Qualified Medical Evaluator is a physician who has been certified by the California Division of Workers’ Compensation to evaluate injured workers in workers’ compensation cases.
What is the role of the claims administrator in the QME appointment notification process?
The claims administrator is responsible for receiving the completed appointment notification form from the QME ensuring that the injured worker’s claim is managed appropriately.
Define ‘medical-legal examination’ in the context of QME regulations.
A medical-legal examination is an assessment performed by a QME to determine the extent of an injured worker’s injuries the necessity for treatment and the impact on the worker’s ability to work often used in workers’ compensation cases.
What is the significance of Section 110 in the QME appointment process?
Section 110 outlines the requirements and procedures for notifying involved parties about a QME appointment ensuring proper communication and administration of workers’ compensation claims.
What is the time frame for sending the appointment notification form after scheduling?
The completed appointment notification form must be sent within 5 business days of the date the appointment was made.
What is required if a Qualified Medical Evaluator (QME) moves to another medical office?
If a QME moves to another medical office that is listed with the Medical Director as an additional office location the QME must include this notification in their communication.
What must a QME include in their notification regarding the need for an interpreter?
The QME shall specify whether a Certified Interpreter is required as defined by Labor Code Section 5811 and subject to the provisions of section 9795.3 of Title 8 of the California Code of Regulations and must specify the language needed.
Who is responsible for arranging the Certified Interpreter and who pays the cost?
The party who is responsible for paying the cost of the Certified Interpreter is also the one who must arrange for the interpreter’s services as stated in Section 5811 of the Labor Code.
What is the minimum notice period a QME must provide when canceling a scheduled appointment?
An evaluator whether AME Agreed Panel QME or QME shall not cancel a scheduled appointment less than six (6) business days prior to the appointment date except for good cause.
What should an evaluator do when they cancel a scheduled appointment?
Whenever an evaluator cancels a scheduled appointment they must advise the parties in writing of the reason for the cancellation.
Who retains jurisdiction to resolve disputes related to appointment cancellations?
The Appeals Board retains jurisdiction to resolve disputes among the parties regarding whether an appointment cancellation was for good cause.
Define ‘good cause’ in the context of canceling a scheduled appointment for a QME.
‘Good cause’ refers to a valid justifiable reason that permits an evaluator to cancel a scheduled appointment less than six (6) business days prior to the appointment date.
What is the role of the Administrative Director in relation to Agreed Panel QMEs or QME?
The Administrative Director retains jurisdiction to take appropriate disciplinary action against any Agreed Panel QME or QME for violations of the specified regulations.
What is the time frame for rescheduling an appointment if a QME cancels?
If a QME cancels a scheduled appointment they must reschedule the appointment to a date within 30 calendar days of the cancellation date.
What is the maximum time frame for scheduling a rescheduled appointment from the date of the initial request?
The rescheduled appointment date may not be more than 60 calendar days from the date of the initial request for an appointment unless the parties agree in writing to accept a date beyond the 60-day limit.
What is the rescheduling requirement for an Agreed Medical Evaluator who cancels an appointment?
An Agreed Medical Evaluator who cancels a scheduled appointment must reschedule it within 60 calendar days of the cancellation unless the parties agree in writing to accept an appointment date no more than 30 calendar days beyond this 60-day limit.
What happens if relevant medical records are not received according to the regulations mentioned?
Failure to receive relevant medical records is addressed under section 35 of Title 8 of the California Code of Regulations and section 4062.3 implying that there could be obligations or consequences depending on the specifics outlined in these sections.
What is the definition of Agreed Panel QME?
An Agreed Panel Qualified Medical Evaluator (QME) is a medical professional designated to evaluate and provide an opinion regarding worker’s compensation claims typically agreed upon by the involved parties to ensure impartiality.
What must be included in a written agreement regarding rescheduling dates?
Any written agreement regarding rescheduling dates must explicitly state that the parties accept a date that exceeds the established 30-day or 60-day limits for rescheduling.
What section of the California Code of Regulations addresses medical records pertinent to QMEs?
Section 35 of Title 8 of the California Code of Regulations addresses the necessity and guidelines for obtaining relevant medical records for QMEs.
Which section of the California Code of Regulations outlines the disciplinary actions for QME violations?
The disciplinary actions for QME violations are governed by the regulations to which the Administrative Director has jurisdiction though the specific section related to disciplinary measures is not named in the provided text.
What happens if the parties do not agree to an extended date for the rescheduling of an appointment?
If the parties do not agree to an extended date for rescheduling outside of the 30 or 60 day limits the original time frames must be adhered to thereby requiring the rescheduling to occur within the stipulated durations.
What constitutes good cause for cancelling an appointment with an evaluator under the Labor Code?
Good cause for cancelling an appointment with an evaluator according to the Labor Code is defined as situations where the evaluator is a psychiatrist or psychologist performing an evaluation regarding a disputed injury to the psyche. In such cases the evaluator must state in the evaluation report that receipt of relevant medical records prior to the evaluation was necessary to conduct a full and fair evaluation.
What is the minimum notice period required to cancel or reschedule an appointment with an evaluator?
An appointment scheduled with an evaluator whether an AME Agreed Panel QME or QME shall not be cancelled or rescheduled by a party or the party’s attorney less than six (6) business days before the appointment date except for good cause.
What should be included in the written notice when cancelling an appointment with an evaluator?
Whenever a cancellation of an appointment scheduled by an evaluator occurs the cancellation must be made in writing must state the reason for the cancellation and must be served on the opposing party. Additionally oral cancellations must be followed with a written notice.
What are the types of evaluators mentioned in the Labor Code regarding appointment cancellations?
The types of evaluators mentioned include Agreed Medical Evaluator (AME) Agreed Panel Qualified Medical Evaluator (QME) and Qualified Medical Evaluator (QME).
How does the role of the evaluator differ when they are a psychiatrist or psychologist in relation to disputed psyche injuries?
When an evaluator is a psychiatrist or psychologist performing an evaluation regarding a disputed injury to the psyche they require relevant medical records prior to the evaluation for a full and fair assessment which is considered good cause for the cancellation of an appointment.
What is the consequence of not adhering to the notice period for cancelling an evaluator appointment?
Failing to adhere to the six (6) business day notice period for cancelling or rescheduling an appointment without good cause may lead to issues regarding compliance with the Labor Code potentially affecting the evaluation process.
What happens if an appointment with an evaluator is cancelled orally?
If an appointment with an evaluator is cancelled orally the cancellation must still be followed up with a written notice stating the reason for the cancellation.
Who must serve the written cancellation notice to the opposing party?
The claims administrator or if none is present the employer the injured worker or either party’s attorney must serve the written cancellation notice to the opposing party.
What is required of a confirming letter sent after a verbal cancellation?
A confirming letter must be faxed or mailed by first class U.S. mail within twenty-four hours of the verbal cancellation and must comply with the applicable section.
What is the liability of an injured worker in relation to missed appointment fees?
An injured worker shall not be liable for any missed appointment fee whenever an appointment is cancelled for good cause.
Who retains jurisdiction to resolve disputes regarding appointment cancellations?
The Appeals Board retains jurisdiction to resolve disputes regarding whether an appointment cancellation by a party was for good cause.
How is the date of cancellation determined when the appointment is cancelled by mail?
The date of cancellation is determined from the date of postmark if mailed.
How is the date of cancellation determined when the appointment is cancelled by fax?
The date of cancellation is determined from the facsimile receipt date as shown on the recipient’s fax copy.
Where can the form mentioned in the document be obtained?
The form can be obtained at no charge by downloading from the web at www.dir.ca.govdwcforms.html or by requesting it at 1-800-794-6900.
Which sections of the Labor Code are cited as authority for the information provided?
Sections 133 139.2 and 5307.3 of the Labor Code are cited as the authority.
What are the sections of the Labor Code referenced in the document?
The referenced sections are 4060 4061 4062 4062.1 4062.2 and 4067 of the Labor Code.
When was the new section filed and what is its operative date?
The new section was filed on 8-1-94 and became operative on 8-31-94.
What is the significance of the Register number mentioned in the history section?
The Register number 94 No. 31 indicates the official publication number where this rule was recorded.
What does the term ‘good cause’ refer to in the context of appointment cancellations?
‘Good cause’ refers to a valid reason for cancelling an appointment excluding liability for missed appointment fees.
