9. Apportionment and reapportionment 2 Flashcards
What sections pertain to the medical director’s role in assigning evaluators?
The medical director’s role in assigning evaluators pertains to Section 122 for appointment and Section 4062.1 for requests by employees or employers.
What is the significance of providing a written statement of reasons for termination or denial?
Providing a written statement of reasons for termination or denial ensures transparency in the decision-making process and allows the physician an opportunity to respond and challenge the decision.
In what time frame must the administrative director notify the physician of the final decision after the physician’s response?
The administrative director must notify the physician of the final decision within 60 days after receipt of the physician’s response.
What is the time frame for assigning a panel after receiving a request?
A panel must be assigned within 20 working days after receiving a request.
What preference is given in assigning panels?
Preference in assigning panels shall be given to cases in which the employee is not represented.
What can an employee do if a panel is not assigned within 20 working days?
If a panel is not assigned within 20 working days the employee has the right to obtain a medical evaluation from any qualified medical evaluator of his or her choice within a reasonable geographic area.
How are panels of qualified medical evaluators assigned?
Panels of qualified medical evaluators are assigned using a random selection method by the medical director.
What types of specialists will the medical director select for the panels?
The medical director shall select evaluators who are specialists of the type requested by the employee.
What advice does the medical director provide to the employee regarding specialists?
The medical director advises the employee to consult with his or her treating physician prior to deciding which type of specialist to request.
Who is responsible for creating the notification form for the selected physicians?
The administrative director is responsible for promulgating a form that notifies the employee of the physicians selected for his or her panel.
What information must the form include regarding each physician on the panel?
The form must include details for each physician on the panel although specific details have not been provided in the text.
Under which sections is the request for a panel made?
Requests for a panel are made pursuant to Section 4062.1 or 4062.2.
Why is it important for an employee to be aware of the panel assignment process?
Understanding the panel assignment process helps employees know their rights and options if there are delays or lack of representation in their cases.
What information must be included about the physician when advising an employee regarding an examination?
The physician’s name address telephone number specialty number of years in practice and a brief description of his or her education and training.
What rights does an employee have regarding transportation and temporary disability expenses for the examination?
The employee is entitled to receive transportation expenses and temporary disability for each day necessary for the examination.
What must be clearly stated about consulting an information and assistance officer?
Employees have the right to consult with an information and assistance officer at no cost prior to selecting the doctor for their evaluation.
What alternative consultation does an employee have other than an information and assistance officer?
Employees may also consult with an attorney.
What will the workers’ compensation administrative law judge consider if a claim goes to court?
The judge will consider the evaluation prepared by the doctor selected by the employee to decide the claim.
What criteria must be met when compiling a list of evaluators for selection?
The evaluators must not have a conflict of interest in the case as defined by relevant regulations.
What is the role of the medical director in selecting evaluators for an employee’s case?
The medical director shall compile a random list of qualified medical evaluators who meet the established criteria.
What does ‘conflict of interest’ mean in the context of selecting a medical evaluator?
A conflict of interest refers to a situation where the evaluator has a personal or professional interest that could impair their impartiality in evaluating the case.
What is the significance of consulting an information and assistance officer for the employee?
It ensures the employee understands their rights and options prior to selecting a doctor for the evaluation.
In the context of workers’ compensation why is the selection of an evaluator important?
The selected evaluator’s assessment can significantly impact the outcome of the claim as it will be considered authoritative in legal proceedings.
What certification is required for an evaluator according to the regulations mentioned?
An evaluator must be certified by the administrative director to evaluate in an appropriate specialty and at locations within the general geographic area of the employee’s residence.
How many locations is an evaluator allowed to conduct qualified medical evaluations?
An evaluator shall not conduct qualified medical evaluations at more than 10 locations.
What are the conditions under which an evaluator may be suspended or terminated as a qualified medical evaluator?
An evaluator may be suspended or terminated for failure to pay the fee required by the administrative director or for any other reason as determined by the administrative director.
What does the medical director do when there are not enough qualified medical evaluators of a specific type within the employee’s geographic area?
The medical director shall include sufficient qualified medical evaluators from the geographic area of the employee’s residence to establish a three-member panel.
Who is responsible for paying the necessary costs associated with the evaluation?
The employer shall pay all necessary costs associated with establishing a qualified medical evaluation panel.
What criteria must be satisfied for an employee to request a qualified medical evaluation?
The employee must request an evaluation by a type of specialist that is deemed appropriate for their specific injury.
What is the role of the medical director in the selection of qualified medical evaluators?
The medical director ensures that sufficient qualified medical evaluators are included to form a three-member panel when there are insufficient evaluators of a specific type in the employee’s area.
What are the travel costs incurred in the event that an employee selects an evaluator from another geographic area?
Travel costs may include expenses such as transportation (airfare mileage reimbursement for driving etc.) lodging meals and any additional costs necessary for the evaluator to conduct the evaluation in accordance with standard company or legal practices.
Who is responsible for reviewing the quality of comprehensive medical evaluations according to Section 122?
The medical director appointed pursuant to Section 122 is responsible for continuously reviewing the quality of comprehensive medical evaluations and reports prepared by agreed and qualified medical evaluators.
What aspects of the evaluation reports does the medical director review?
The medical director reviews the quality of the evaluations and reports the timeliness of their preparation and submission a random sample of reports submitted to the division and reports alleged to be inaccurate or incomplete by any party to a case.
What is the purpose of the medical director’s annual report?
The purpose of the medical director’s annual report is to summarize the results of the continuous review of medical evaluations and reports and to make recommendations for the improvement of the system of medical evaluations and determinations.
What section addresses the public hearing mentioned regarding additional procedures?
Section 5307.3 j addresses the public hearing pursuant to the review and evaluation of medical reports and determinations.
What types of evaluators are discussed in relation to Section 122 and Section 5307.3 j?
Agreed and qualified medical evaluators are discussed in relation to Section 122 and Section 5307.3 j.
Is the review by the medical director limited to only the reports submitted or does it include any additional checks?
The review is not limited to just the reports submitted; it includes a review of a random sample and reports alleged to be inaccurate or incomplete indicating a thorough approach to the evaluation.
What might be included in the recommendations made by the medical director in the annual report?
The recommendations may include suggestions for improving the accuracy efficiency and clarity of medical evaluations and reports enhancing training for evaluators or modifying procedures related to the evaluation process.
Define ‘comprehensive medical evaluations’ as used in the context of Sections 122 and 5307.3 j.
Comprehensive medical evaluations refer to thorough assessments conducted by medical evaluators to determine an individual’s medical condition functional abilities and any potential work-related injuries or disabilities ensuring that all relevant factors are considered in the evaluation.
What section outlines the regulations regarding timeframes for medical evaluations?
Section 5307.3 outlines the regulations concerning the timeframes within which medical evaluations shall be prepared and submitted by agreed and qualified medical evaluators.
What is the maximum timeframe for initial medical evaluations to be prepared and submitted after the evaluator’s initial assessment?
The maximum timeframe for initial medical evaluations to be prepared and submitted shall be no more than 30 days after the evaluator has seen the employee or otherwise commenced the medical evaluation procedure.
Under what circumstances can the 30-day period for medical evaluations be extended?
The 30-day period for medical evaluations can be extended in two cases: 1. Evaluator Time Constraints - when the evaluator has not received test results or consulting physician’s evaluations in time to meet the 30-day deadline. 2. Good Cause Extensions - an extension by not more than 15 days when the failure to meet the 30-day deadline was for good cause.
What authority does the administrative director have concerning the timeframe regulations?
The administrative director shall adopt regulations concerning the timeframes for medical evaluations and develop regulations governing the provision of extensions of the 30-day period.
What is the maximum extension period that can be granted under the ‘Good Cause Extensions’?
The maximum extension period that can be granted under the ‘Good Cause Extensions’ is not more than 15 days.
Explain ‘Evaluator Time Constraints’ as it pertains to extension regulations.
‘Evaluator Time Constraints’ refers to situations where the evaluator has not received necessary test results or evaluations from consulting physicians in time to meet the initial 30-day deadline for submitting the medical evaluation.
What is the purposes of subparagraph A in the context of Section 5307.3?
Subparagraph A serves to clarify the conditions under which extensions to the 30-day deadline for medical evaluations can be granted specifically addressing evaluator time constraints and good cause scenarios.
What does ‘good cause’ refer to in the context of medical evaluations?
‘Good cause’ includes the following circumstances: 1. Medical emergencies involving the evaluator or their family. 2. Death in the evaluator’s family. 3. Natural disasters or community catastrophes that disrupt the evaluator’s business operations.
What is the role of the administrative director regarding qualified medical evaluators?
The administrative director is responsible for developing timeframes that govern the availability of qualified medical evaluators for unrepresented employees as specified in Section 4062.1.
What rights do employees have concerning the selection of medical evaluators if an evaluator is not available?
Employees have the right to add a new evaluator to their panel selected at random for each evaluator unavailable to see them within a specified timeframe. However they can waive this right for a specified period.
Which sections govern the procedures for evaluating permanent impairment and limitations from injuries?
The procedures for evaluating the existence and extent of permanent impairment and limitations are consistent with Sections 4660 and 4660.1.
What must be determined when there is a dispute regarding medical evaluations?
Procedures must be established to govern the determination of any disputed medical evaluations.
What does Section 5307.27 pertain to?
Section 5307.27 addresses treatment issues related to specific injury claims ensuring compliance with regulations and procedures for compensability determination.
What procedures must be followed to determine the compensability of psychiatric injury according to Section 3208.3?
The procedures must include a diagnosis using the terminology and criteria provided in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders Third Edition-Revised.
What is the role of the Diagnostic and Statistical Manual of Mental Disorders in psychiatric injury claims?
The DSM provides the terminology and diagnostic criteria necessary for establishing a mental disorder in the context of compensability for psychiatric injuries.
What guidelines must be established regarding medical-legal evaluations?
Guidelines must establish minimum times for patient contact during medical-legal evaluations and be consistent with regulations adopted under Section 5307.6.
What are some examples of treatment procedures that need defined and valued standards according to Section 5307.1?
Treatment procedures that have not been explicitly defined or valued per Section 5307.1 requiring assessment for proper handling and compensability.
Who can request evaluation procedures beyond those outlined in the relevant sections?
Evaluation procedures can be requested by the Insurance Commissioner or may be deemed appropriate by the evaluating authority.
What is the significance of Section 5307.6 in relation to medical-legal evaluations?
Section 5307.6 establishes the regulations and value definitions for medical-legal evaluations ensuring clarity and structure in compensation determinations.
What are the implications of not having specific values for treatment procedures in a psychiatric injury case?
Not having specific values can lead to inconsistencies in treatment standards and difficulty in determining appropriate compensation for psychiatric injuries.
How do the minimum time guidelines for patient contact influence psychiatric evaluations?
Minimum time guidelines are intended to ensure thorough evaluations and adequate patient interaction to accurately determine the degree of injury and needs for care.
In therapeutic contexts why is it necessary to establish defined values for treatment procedures?
Defined values ensure uniformity in treatment approaches enable fair compensation and provide clarity in legal and medical evaluations for psychiatric cases.
What role does the administrative director have regarding medical evaluators?
The administrative director has the discretion to suspend or terminate the privilege of a physician to serve as a qualified medical evaluator if certain conditions are met.
What must be established as a condition for the appointment or maintenance of a medical evaluator?
Medical evaluators must meet additional medical or professional standards as a condition of appointment reappointment or maintenance in the status of a medical evaluator.
