7 Case Studies (1-2 hrs.)

Question 1

When an IW had jobs involving similar work or body mechanics in 1985, 1991, 1998, and 2002 but did not realize she was having a problem requiring treatment and/or causing her impairment/disability until 2002, what would the Date of Injury be

Answer 1

2002

Question 2

If immediate/emergency treatment is required because of a serious or life-threatening situation, the provider’s treatment must still meet the requirement of being consistent with the MTUS and approved before treatment is rendered.

Answer 2

No

Question 3

If the evaluator determines that the IW’s pain increases the burden of the IW’s ADLs even slightly, the evaluator may add-on to the IW’s impairment how much for pain.

Answer 3

1%-3% whole person impairment

Question 4

If an IW has stand-alone headache pain with no other impairment for any other body part or system, the evaluator can do which of the following with regard to an
impairment rating:

Answer 4

Headache pain can be given an impairment rating of between 1%-3% WPI

Question 5

If an IW’s right knee was injured in 2002 and the case was settled with a Stipulated Award and a PD rating of 10% and the IW re-injured the same knee again in 2007 with a PD rating of 20%, which of the following applies with regard to apportionment

Answer 5

Apportionment applies because it is presumed that a prior PD for the same body part is permanent and still exists.

Question 6

In a psyche injury claim, if the QME believes that the IW would be at risk by sending the IW a copy of the QME report with opinions and conclusions about the IW’s mental & behavioral status and with regard to mental health records reviewed, the QME should do which of the following?

Answer 6

Insist that the IW must retain an attorney, who can then share the report with the IW

Complete a QME Form 121 to protect the disclosure of mental health records

Question 7

An employee on vacation was asked by his supervisor to take one of the company’s clients out to dinner. While doing so, the employee fell and broke her leg. Given this situation, which of the following would best characterize the nature of causation in this case

Answer 7

AOE - The injury arose from employment but did not occur during the course of
employment

Question 8

An employee was injured in a motor vehicle accident while leaving his job in his car to go home. In this situation causation would be properly interpreted as follows:

Answer 8

There was no industrial causation because a normal commute to and from work is not considered to be AOE or COE

Question 9

In a situation where a QME has referred the IW out for imaging diagnostics to a radiology group in which the QME’s brother-in-law is a partner, which of the following applies?

Answer 9

The QME must disclose the relationship on a financial conflict of interest form with the AD before proceeding with the referral

Question 10

A QME’s evaluating a simple and routine low back sprain/strain for 5 minutes that had resolved with no need for further treatment, no need for an impairment rating, there was no apportionment indicated, no need for future medical care and no need to provide a report was objected to because of which of the following reasons

Answer 10

The QME spent less than 20 minutes face-to-face time evaluating the IW with no explanation and did not provide a report

Question 11

Which of the following is not a routine Activity of Daily Living, per the AMA Guide to the Evaluation of Permanent Impairment (5th Ed.)

Answer 11

Ability to work

Question 12

A low back injury to a sedentary, light work individual such as a secretary may not substantially infringe upon the secretary’s ability to work, but the same injury in a heavy construction worker might be a career ending injury. Therefore, under SB899, the best way to measure impairment is based upon:

Answer 12

The routine Activities of Daily Living which everyone must do irrespective of their job

Question 13

An injured worker who routinely lifted over 50 pounds repetitively throughout the work day was injured and can now, while being treated and recovering, only lift 20 pounds or less and this injured worker is now being accommodated with light work
in a sedentary job. This situation would be classified as:

Answer 13

A reasonable accommodation

Question 14

In a case involving an unrepresented injured worker with a DOI after 2005 where there is a dispute with the employer/insurance carrier, the following can be selected for evaluation to resolve the dispute:

Answer 14

Panel QME

Question 15

A QME who uses an assisting nurse to take and record vital signs, a historian to review records and interpret them for the QME, and a clerical worker who transcribes the QME’s report has done which of the following:

Answer 15

Violated under penalty of perjury that the QME reviewed the records; even if the QME uses a historian, the QME needs to also review their work and the records and name them in the report as assisting in the production of the report

Question 16

If an IW is cut on the job, treated on the job with first aid and then sees a doctor for follow up, who returns the IW to work without any restrictions or limitations, the incident should be:

Answer 16

Considered a minor first aid incident with no claim filed

Question 17

An IW who had fractured her fibula in a fall on steps at work was provided with appropriate treatment and rehabilitation, eventually being returned to work with no job-limiting preclusions/restrictions. When finally evaluated, it was determined that her routine ADLs were not affected, and there were no positive examination findings but the evaluating QME gave her a 3% rating for pain. Which of the following would be true?

Answer 17

No impairment rating should have been given for pain with a 0% rating

Question 18

When evaluating an IW with impairment to three separate body parts, (e.g., elbow, low back, and knee), how should the impairment values for each body party be handled to establish an overall combined whole-body impairment rating?

Answer 18

The values for each body part should be combined using the Combined Values Chart (Page 604) in the AMA Guide (5th Ed.) starting with the highest value (Yes, per the AMA Guides – but not the state of CA, which wants you to bring each body part to a whole person impairment rating and leave it alone)

Question 19

An IW who is being accommodated by their employer with modified work duty should receive temporary disability compensation only if the following is true:

Answer 19

Only if the modified work pays less than 85% of the IW’s salary/earnings that were being paid at the time of the injury

Question 20

If a licensed doctor is not a QME but both parties in a represented case, (both attorneys), agree to use the doctor as an AME to perform a medical-legal evaluation to resolve a disputed issue, it is legally permissible.

Answer 20

True

Question 21

If a person reviews the records for a QME for purposes of organizing and consolidating the records, it is considered:

Answer 21

Permissible if the activity is described in the QME’s report and is identified in the report - The QME can only charge for the time that they have spent with the records

Question 22

If a QME contacts the PTP to gather more information, ask questions or inquire about records, it is considered to be:

Answer 22

Legal and does not constitute ‘ex parte’ communication, but the contact and nature of the information/records obtained should be described in the QMEs report

Question 23

Can an IW request to see the QME’s curriculum vitae, license or QME certificate at the time of the face-to-face evaluation?

Answer 23

Yes

Question 24

If a QME’s report is late, (i.e., served more than 30 days after the evaluation), which of the following parties has the right to object to the QME’s report?

Answer 24

Only parties in a represented case

Only an unrepresented injured worker

Only the insurance carrier’s claims adjustor

Question 25

If a QME has previously treated the IW scheduled to be evaluated, under which circumstances can the QME proceed to evaluate the IW without a conflict of interest?

Answer 25

Never. It is always a conflict of interest

Question 26

When a QME completes a report in an unrepresented case where the IW is found to be permanent & stationary and has been given a final impairment rating, where
should the report be sent besides providing copies to the IW and to the insurance
carrier?

Answer 26

DEU

Question 27

In an unrepresented case, if the DEU has not issued a summary rating determination, where should a QME’s supplemental report be sent to?

Answer 27

A supplemental report should not be issued until a determination is made

Question 28

In a case involving a low back injury, the QME concluded that 50% of the IW’s impairment should be apportioned to minimal degenerative disc disease (DDD) which appears on pre-injury x-rays. The QME opined that at least 50% of the IW’s impairment/disability would have resulted in the future anyway absent the industrial
injury. The IW objected because she said that she had no pre-injury complaints and no pre-injury need for professional or self-treatment and because there were no formally imposed or self-imposed activity/work limitations before the industrial injury and that she could perform all of her ADLs without a problem pre-injury. In this case, which of the following best describes the QME’s conclusion?

Answer 28

It was incorrect because you can only apportion to the cause of disability/impairment and because it is speculation to assume the onset of impairment at some unknown, non-specific time in the future unless the pathology involved has a scientifically established progression, and the DDD is minimal

Question 29

In a claim involving a convenience store hold-up where the employee was physically injured, the IW also claimed psychological injury. Given this situation, which of the following is the most correct answer?

Answer 29

If a psych injury claim is the result of experiencing or witnessing a violent act and it can be proved that at least 35% of the psych injury resulted from violence experienced or witnessed on the job, it is both treatable and ratable

Question 30

Post-termination, an employee filed a claim because he said that his termination caused him psychological harm and stress, and he demonstrated that more than
51% of his stress was caused by the termination action. Which is correct?

Answer 30

In a ‘good faith personnel action’, there is no legal basis for a psych claim; however, if the employer purposefully embarrassed the employee in front of other people,
ridiculed, made fun of, or threatened them, etc. the employer may have issues

Question 31

In a represented case, both attorneys received the same QME panel list with three QMEs listed on it in the specialty requested. Both attorneys agreed to the same QME from list, therefore:

Answer 31

The panel QME was agreed to and can charge 25% more for their QME services

Question 32

In 2008 a workers’ compensation claim with a Date of Injury (DOI) in 2001 was re-evaluated and the IW was finally found by the QME to be permanent & stationary for purposes of providing a final rating. Given the DOI, which of the following is most correct and applicable in this situation?

Answer 32

Under SB899, all cases made permanent & stationary after 2005 are rated using the AMA Guide (5th Ed.) impairment rating system

Question 33

After the injured employee completes/files a DWC 1 Claim Form, the employer has how many days to provide the form to the claims administrator, employee, dependent or representative?

Answer 33

1 working day

Question 34

A QME may perform a medical-legal evaluation in which situations?

Answer 34

Panel QME (PQME) in an unrepresented case

Panel QME in a represented case – strike process – 1 QME left

Agreed PQME in a represented case – 1 QME agreed to on the panel

Agreed Medical Evaluation – no panel

Question 35

BONUS: If impairments in both the left and right hands create a synergistic effect leading to a greater overall impairment than if different body parts were affected, what landmark case allows the QME to ADD these impairment ratings instead of COMBINING them?

Answer 35

The Kite case. The Kite Case allows for the adding of impairment ratings for different body parts. “Adding” 8% and 4% results in 8% + 4%= 12%. “Combining” 8% and 4% (per the Combined Values Chart on page 604 of the AMA Guides) equals 10%. Notice how “adding” yields a higher impairment value.