8 Review Quiz (1-2 hrs.) Flashcards
Review your knowledge
1
Q
P&S means that residual impairment or disability exists (True/False)
A
FALSE, there may be impairment or no impairment
1
Q
Discharged as cured means the condition has resolved (True/False)
A
TRUE
2
Q
Pre-injury status means the condition has resolved (True/False)
A
TRUE
3
Q
The standard to prove causation is not medical certainty, but a reasonable medical probability (True/False)
A
TRUE
4
Q
Any doctor/acupuncturist who has treated the worker cannot be the QME (True/False)
A
TRUE
5
Q
Is there a limit to temporary disability benefits (TTD)?
A
Yes, 2 years
6
Q
A QME or AME should not:
A
Use a PR-3 (PTP, P&S Report - Permanent Disability Report - Pre 2005 injuries)
Use a PR-4 (PTP, P&S Report - Permanent Impairment Report - Post 2005 injuries)
Solicit the worker to become a patient
Make the patient wait more than an hour to be seen
7
Q
How long does Future Medical care last?
A
Forever.
8
Q
Per Labor Code 4600 what medical/hospital treatment is provided by the employer?
A
Medical, chiropractic, surgical and acupuncture care
Hospital treatment including nursing
Medicines, medical and surgical supplies
Crutches, apparatuses, including orthotic and prosthetic devices and services
9
Q
In the California Workers’ Compensation System, a physician is?
A
M.D., D.C., D.O.
D.P.M, Ph.D., D.D.S.
L. Ac., O.D.
10
Q
Impairment is considered permanent when it has reached MMI (True/False)
A
TRUE
11
Q
Permanent and stationary (P&S) means that the condition will LIKELY never change (True/False)
A
TRUE
12
Q
Which reports are admissible at the WCAB?
A
Reports from the PTP
Reports from the QME or AME
13
Q
100% total disability is presumed to exist in which of the following injuries?
A
Loss of both of the worker’s eyes or the sight thereof
Loss of both of the worker’s hands or use thereof
Practically total paralysis
A brain injury resulting in incurable mental incapacity or insanity
14
Q
QMEs are limited to 10 locations to evaluate injured workers (True/False)
A
TRUE
15
Q
QME panels are picked within geographic region of the worker’s home residence OR work (True/False)
A
TRUE
16
Q
In which of the settings below must interpreting services, be provided to an injured worker who does not speak or understand English?
A
A deposition
Appeals Board hearing
Medical-legal examination
Medical treatment appointment
17
Q
The initial appointment location can never be moved; however subsequent evaluations can be done at another office as long as the QME has it listed with the DWC-Medical Unit (True/False)
A
TRUE
18
Q
Each new PTP must complete a Doctor’s First Report of Occupational Injury or Illness (Form DLSR 5021) following the initial examination. (True/False)
A
TRUE
19
Q
Medical treatment is designed to cure or relieve the effects of the industrial injury. (True/False)
A
TRUE
20
Q
If an injured worker’s claim is not accepted or denied within 90 days of the worker giving the completed Claim Form (DWC Form 1) to the employer, the claim is presumed to be industrial. And, the claims administrator is liable for up to $10,000 in treatment under the medical treatment guidelines, while considering the claim. (True/False)
A
TRUE
21
Q
Workers’ compensation benefits are the only exclusive remedy for injuries suffered on the job when the employer is properly insured. If the employer is illegally uninsured, the worker can file a civil action against the employer, in addition to filing a workers’ compensation claim. (True/False)
A
TRUE
22
Q
A medical provider network (MPN) is a group of healthcare providers set up by the employer’s insurance company and approved by the DWC’s administrative director to treat workers injured on the job. (True/False)
A
TRUE
23
Q
The 24-visit cap on chiropractic care, physical therapy and occupational therapy, does not apply to dates of injury before 1-1-04. (True/False)
A
TRUE
24
Temporary Disability payments provided to an injured worker for a date of injury on/after 1-19-04 are limited to 104 weeks. For certain injuries, temporary disability shall not last for more than 240 weeks. Those injuries include:
* Acute and chronic hepatitis B and C
* Amputations
* Severe burns
* Human immunodeficiency virus (HIV)
* High-velocity eye injuries
* Chemical burns to the eyes
* Pulmonary fibrosis
* Chronic lung disease.
25
The Labor Code (3600) specifically excludes from compensation 7 types of injuries contained in the Physician’s Guide. Those include:
* Injuries caused by the employee’s use of alcohol or illegal controlled substances (if it can be shown that the injury would not have occurred otherwise)
* Intentionally self-inflicted injuries
* Suicide, if willful and deliberate
* Injuries resulting from altercations, in which the injured employee is the ‘initial physical aggressor’
* Injuries resulting from the employee’s commission of a felony, for which the employee has been convicted
* Injuries resulting from off-duty recreational activities, where participation in the activities does not constitute part of the employee’s work-related duties, and where the activity is not an expressed or implicit condition of employment
* Psychiatric injuries claimed after notice of termination/layoff unless certain conditions exist
26
CC&R 9768.10 indicates that IMR doctors can be an MD, DO or DPM. (True/False)
TRUE
27
A ‘Secondary Physician’ is any physician other than the primary treating physician who examines or provides treatment to the employee, but is not primarily responsible for continuing management of the care of the employee. (True/False)
TRUE
28
A medical-legal report shall contain a declaration by the physician signing the report, under penalty of perjury, stating, “I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as to information that I have indicated I received from others. As to that information, I declare under penalty of perjury that the information accurately describes the information provided to me and, except as noted herein, that I believe it to be true.” The foregoing declaration shall be dated and signed by the reporting physician and shall indicate the county wherein it was signed. (True/False)
TRUE
29
A QME who has not paid their recertification fees or let their QME certification lapse, cannot perform a re-evaluation of the patient, however, can perform a supplemental report, where the worker is not examined. (True/False)
TRUE
30
A QME may obtain a consultation from any physician as a reasonable and necessary expense. (True/False)
FALSE
31
The evaluator and the employee’s treating physician(s) may consult as necessary to produce a complete and accurate report. (True/False)
TRUE
32
All communications by the parties with the medical-legal evaluator shall be in writing and sent simultaneously to the opposing party when sent to the medical evaluator. (True/False)
TRUE
33
Represented parties who have selected an Agreed Medical Evaluator or an Agreed Panel QME shall, as part of their agreement, agree on what information is to be provided to the AME or Agreed PQME. (True/False)
TRUE
34
An evaluator shall not request or accept any compensation or thing of value from any source that does or could create a conflict with his or her duties as an evaluator. (True/False)
TRUE
35
No physician reporting as an AME or QME shall accept gifts that have a total fair market value in the aggregate of $360 or more, from any single source that handles California workers’ compensation matters, in the course of any consecutive 12 months. The sources include, but are not limited to, 1 or more attorneys, physicians, employers, claims administrators, medical or health care or insurance or utilization review business entities. (True/False)
TRUE
36
“Primary treating physician’ is the physician who is primarily responsible for managing the care of an employee, and who has examined the employee at least once for the purpose of rendering or prescribing treatment and has monitored the effect of the treatment thereafter. (True/False)
TRUE
37
“Released from care” means a determination by the PTP that the employee’s condition has reached a permanent and stationary status with no need for continuing or future medical treatment. (True/False)
TRUE
38
“Future medical treatment” is treatment which is anticipated at some time in the future and is reasonably required to cure or relieve the employee from the effects of the injury. (True/False)
TRUE
39
“Continuing medical treatment” is occurring or presently planned treatment that is reasonably required to cure or relieve the employee from the effects of the injury. (True/False)
TRUE
40
An employee shall have no more than 1 primary treating physician at a time. (True/False)
TRUE
41
Secondary treating physicians, physical therapists, and other health care providers to whom the employee is referred shall report to the PTP in the manner required by the PTP. (True/False)
TRUE
42
When continuing medical treatment is provided, a progress report (Form PR-2) shall be made no later than 45 days from the last report. (True/False)
TRUE
43
The QME or AME evaluates an injured worker, however, there is not enough time to finish the evaluation and the employee is asked to return to the office on another date to complete the process. The 30 days to serve the report on the parties starts on the first day the worker was seen. (True/False)
TRUE
44
In unrepresented cases an AME cannot be used. (True/False)
TRUE
45
The AMA’s ‘Guides to the Evaluation of Permanent Impairment’, Fifth Edition is used by the State of California, for the purpose of determining Impairment ratings for dates of injury on or after 2005. (True/False)
TRUE, AMA 5th Edition for California!!!
46
The term impairment in the AMA 5th Ed. Guides refers to permanent impairment. (True/False)
TRUE
47
The evaluating physician needs to ensure that the examinee understands that the evaluation’s purpose is assessment and not medical treatment. However, if new diagnoses are discovered, the physician has a medical obligation to inform the requesting party and the employee about the condition and recommend further assessment. (True/False)
TRUE
48
The final impairment rating should be rounded to the nearest whole number? (True/False)
TRUE
49
When a worker is injured and plans to file a claim, which of the following should happen to move the case forward?
The worker completes a Workers’ Compensation Claim Form (DWC 1) questions 1 -8 and the employer contributes to this form, questions 9-17
The employer needs to complete an Employer’s Report of Occupational Injury or Illness (Form 5020)
The PTP completes a Doctor’s First Report (DFR) of Occupational Injury or Illness (Form 5021)
50
While serving as a QME/AME it is not permitted to solicit an injured worker to become your patient. However, if the worker asks you to assume a role as a treating physician, and you accept, you cannot be the QME/AME in the future. (True/False)
TRUE
51
A QME must use good clinical judgment in applying the AMA Guides and may utilize any chapter, table or method that most accurately reflects the injured worker’s impairment within, “The four corners” of the Guides. (The Guzman Court of Appeals Decision) (True/False)
TRUE
52
For psychiatric injuries, impairment is not decided by the AMA Guides, but the Global Assessment of Function (GAF) Scores. (True/False)
TRUE
53
A permanent disability/impairment evaluation report cannot be completed if the injured worker’s condition is not permanent and stationary/maximum medical improvement. The rating of impairment and apportionment requires P&S/MMI. (True/False)
TRUE
54
A permanent disability report is for a date of injury before 2005. (True/False)
TRUE
55
A permanent impairment report (AMA) is for a date of injury from 2005 and forward. (True/False)
TRUE
56
Ratings are adjusted for age and occupation. (True/False)
TRUE
57
Temporary disability payments cease when the worker returns to work, or is P&S. (True/False)
TRUE
58
A 1 to 3% add-on rating for pain can only be added if there is a ratable impairment. (True/False)
TRUE
59
A QME must see the worker within 90 days of the request for an appointment. (True/False)
TRUE
60
A QME may see the patient after 90 days by agreement of the scheduling party, however, not beyond 120 days. (True/False)
TRUE
61
The QME Appointment Notification Form (Form 110) shall be submitted within 5 business days. (True/False)
TRUE
62
An oral cancellation of a QME appointment must be followed by a written confirmation. (True/False)
TRUE
63
All communications with a QME must be in writing. (True/False)
TRUE
64
QMEs do not resolve treatment disputes; the IMR process resolves them. (True/False)
TRUE
65
A QME shall advise the injured worker before the examination that he/she is entitled to ask the evaluator questions. (True/False)
TRUE
66
A preponderance of the evidence means, “Such evidence as, when weighed with that opposed to it, has more convincing force and the greater probability of truth.” (True/False)
TRUE
67
The injured worker has the burden of proof to show by a preponderance of the evidence that the injury was work related. (True/False)
TRUE
68
To constitute substantial medical evidence, a medical opinion must be predicated on reasonable medical probability. (True/False)
TRUE
69
QME reports shall be kept for 5 years from the date of each evaluation report. (True/False)
TRUE
70
A medical opinion is not substantial evidence if it is based on an inadequate medical history or examination, incorrect legal theories, facts no longer germane to the case, speculation, surmise, and conjecture or guessing. (True/False)
TRUE
71
Chiropractors are required to take a minimum 25 Hour California Workers Compensation Evaluation Course to be a QME. (True/False)
TRUE
72
A psychologist must have at least 5 years postdoctoral experience in the treatment of emotional or mental disorders. (True/False)
TRUE
73
All physicians must have completed at least a 12 Hour Disability Evaluation Report Writing Program prior to appointment as a QME (Except DCs - 25 Hour Course includes Report Writing) (True/False)
TRUE
74
The State of California uses the most current edition of the AMA Guides to determine impairment.
(True/False)
False - Only the Fifth Edition
75
The AMA Guides - Fifth Edition are only used for dates of injury 1-1-05 and forward. (True/False)
TRUE
76
A QME/AME may only use 1 chapter of the AMA Guides to provide an impairment rating. (True/False)
False - Can use any chapter in the book that is applicable to the injured worker’s condition(s) to provide the most accurate rating
(Almaraz/Guzman)
77
A physician must be a QME to perform medical-legal evaluations and reports. (True/False)
False - PTPs and AMEs do not have to be a QME to write a medical-legal report
78
An AME must be a QME. (True/False)
FALSE. Any Dr can be an AME
79
Are Secondary physician reports, accepted at the WCAB?
NO
80
Are Secondary physician reports, adopted by the PTP accepted at the WCAB?
YES
81
A QME who has treated the injured worker, must disqualify them self if their name appears on the QME panel list. (True/False)
True
82
The DWC - Medical Unit is responsible for providing panel QME lists. (True/False)
True
83
Medical-legal testimony means expert testimony provided by a physician at a deposition or WCAB hearing. (True/False)
True
84
An interpreter shall be provided if the injured worker does not proficiently speak or understand the English language. (True/False)
True
85
An interpreter shall be provided if the injured worker does not proficiently speak or understand the English language. (True/False)
True
86
A comprehensive medical evaluation and report prepared by the PTP when there are no contested or disputed issues is not considered a medical-legal expense and is billed under the Official Medical Fee Schedule (OMFS) and not the Official Medical-Legal Fee Schedule (OMLFS). (True/False)
True
87
Request for Authorization (RFA) is used to request treatment in a work comp claim. (True/False)
True
88
If a new diagnosis/condition is discovered during an evaluation, unrelated to the work comp claim, the evaluator has an obligation to inform the involved parties and recommend further medical assessment. (True/False)
True
89
In the AMA Guides, in situations where impairment ratings are not provided for a particular condition, an analogy to a similar condition should be provided. (True/False)
True. This is know as Almaraz/Guzman cases.
90
To add up to 3% whole person impairment for pain (Chapter 18), no formal assessment of pain-related impairment is required. (True/False)
True. Use CLINICAL JUDGEMENT. Keep in mind Chapter 18 has a pain questionnaire, discussed McGill Pain Questionnaire, and Visual Analogue Scale.
91
The QME/AME physician needs to ensure that the injured worker/patient/examinee understands that that the evaluation’s purpose is medical assessment, not medical treatment. (True/False)
True
92
A permanent impairment rating should not be provided until the patient is permanent and stationary/MMI. (True/False)
True
93
The 8 ADLs listed in Table 1-2 on page 4 of the Guides should be considered when establishing an impairment rating. (True/False)
True
94
Up to 3% whole person impairment may be increased for the effects of treatment or lack of treatment (medication). Pages 20 and 600, AMA Guides. (True/False)
True
95
ADDING VS COMBINING (CVC TABLE)
Adding results in a HIGHER WPI.
Combining, compressed and lowers the WPI. (True/False)
TRUE
96
ADDING VS COMBINING (CVC TABLE)
The CVC Table applies as a default in accordance with the AMA Guides.
When can you ADD whole person impairment (WPI) values?
On July 10, 2024, The Workers' Compensation Appeals Board issued an en banc Decision in Sammy Vigil v. County of Kern. (
(a) there is no overlap between the effects on ADLs as between the body parts rated; or
(b) there is overlap, but the overlap increases or amplifies the impact on the overlapping ADLs.
97
The QME must include face-to-face time with the applicant/patient? (True/False)
TRUE
98
If P&S, fill out and submit DWC AD Form 10133.36 (SJDB) Physician's Return-to-Work & Voucher Report (True/False)
TRUE
99
Case Law
Escobedo v. Marshalls
substantial medical evidence
100
Case Law
Yeager Construction v. Workers' Comp. Appeals Bd.
substantial evidence is reasonable medical probability
101
Employers who contract with HCO can direct tx of IW up to … days.
90 or 180 days following an injury.
102
QME has to schedule a deposition within .. days.
120 days. It takes place w/in 20 miles where IW’s eval took place.
103
The boss (insurer) has … days to accept or deny IW’s claim. In the meantime, IW may receive $….. worth of treatment.
90 days
$10,000
104
In how many days must QME hand in her report after an exam/appointment ?
30 days
105
If you file a petition to appeal IMR, what can WCAB judge do?
He can not make a finding of medical necessity contrary to the final determination of IMR but judge can order a repeat IMR decision to be performed by different Drs.
106
How to appeal IMR and in what time frame?
Filing a petition before a WCAB judge within 30 days of the mailing of the final determination.
107
IF QME has to cancel scheduled app, she must tell the parties in writing the reason and reschedule within ….days of cancelation.
60 days
108
Represented IW. After QME is selected, IW has … days to make an appointment with QME. If they don’t, the boss will arrange it.
10 days
109
An app is made, QME must submit Appointment Notification form (110) within..
5 days
If QME doesn’t do it, a replacement QME panel may be issued
110
CME for QME is ….. hrs in …years
12 hrs in 2 years. Passing QME is 6 hrs
