QME Flashcards
Define QME
Qualified Medical Evaluator
Define AME
Agreed Medical Evaluator. Any Dr can be agreed by both parties to examine for disability. AME may NOT be licensed QME!
Define PTP
Primary Treating Physician.
Define IW
Injured Worker
Define QIW
QIW (Quilified Injured Worker) if they can not return to their job. They get $ to retrain called: Supplemental Job Displacement Benefits (SJDB), PAY OUT
What constitutes an “injury”
a specific trauma or cumulative trauma that results in lost work time and/or interference with an employees ability to work
Define AOE and COE
Arise out of Employment (AOE) + during the Course of Employment (COE) = Compensable work injury
Define Aggravation vs. Exacerbation
An aggravation is a permanent increase in the severity of the preexisting condition.
An exacerbation is a temporary increase in symptoms that resolves, returning you to baseline.
What is the no fault rule
The employer is required to pay benefits no matter who caused the injury.
Liability
Liability for the injury “shall, without regard to negligence, exist against an employer for any injury sustained by his or her employees arising out of and in the course of employment and for the death of any employee if the injury proximately causes death,
When is the Date of Injury (DOI)
the date the employee first suffered disability from the exposure
Specific Injury
Occurs as a result of an incident or exposure which causes any disability or need for medical treatment
Date of CT injury
both disability plus knowledge
“last injurious exposure”
Cumulative Trauma (CT) examples
· Cumulative trauma disorders (CTDs)
· Repetitive Stress Injury (RSI)
· Overuse syndrome
· Repetitive motion disorders
Define Medical Probability
Your opinion or conclusion based the probability 51% or greater.
“More likely than not”
What probability is needed to determine AOE?
“more likely than not”
Substantial medical evidence means
reasonable medical probability
“more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales
What is the definition of permanent and stationary (P&S)?
A worker’s condition has reached Maximal Medical Improvement (MMI) and is unlikely to change substantially within the next year, with or without medical treatment
Define impairment
impairment–deviation from pre-injury state; PTP, QME Rate Impairment in % Whole Person Impairment (WPI) with AMA 5th Edition Guides to the Evaluation of Permanent Impairment
Define disability
disability–problems with function (work limits) due to impairment. Rated by the Disability Evaluation Unit (NOT the PTP or QME)
Who calculates the disability rating?
A DEU rater (Disability Evaluation Unit)
What are DEU forms 100 and 101?
100-Employee’s permanenet disability questionnaire; 101–Request for summary rating determination; both must accompany a QME report
WPI refers to:
Whole Person Impairment uses the AMA 5th Ed. Guides
What is the AMA 3% pain rule?
Physician can add a maximum of 3% to whole person impairment for pain greater than that normally associated with the injury
What 8 categories of ADLs are taken into account to form an impairment rating?
- self-care 2. communication 3. physical activity 4. sensory function 5. non-specialized hand activities 6. travel 7. sexual function 8. sleep
What is the combined valued chart (CVC)?
chart in AMA guides designed to account for effects of multiple body parts impairments with a summary value that won’t exceed 100%
Define UR
Utilization Review, they determine TREATMENT issues
Define IMR
Independent Medical Review, then determine TREATMENT disputes
What is form DWC1?
Work comp claim form used by injured employee to file a benefits claim
What is the relationship between whole person impairment and work restrictions
Physician must qualify work restrictions based on what is impaired; there is no equivalency
How long does a QME have to file a report
30 days for DOI after 1/1/94
When can an injured worker choose their own Primary Treating Physician (PTP) if not predesignated?
30 days after DOI unless signed up for an HCO
What is the pathophysiology of chronic pain?
process in which an injury produces one pathogenic mechanism, which in turn produces others so that the causes of pain change over time to include the loss of spinal inhibitory neurons leading to excitability and abnormal responsiveness in thalamic neuron
What is form RU-90
RU-91?
RU-90 form filled out jointly by employee/insurance company that details job duties
RU-91 QME form for work restriction decisions
Which 4 work factors are consistently highly associated with the onset of disabling pain?
- job dissatisfaction 2. lack of support at work 3. stress 4. perceived inadequacy of income
Define ‘Ex Parte’ communication
Ex Parte = excluding a party from communication. This is legally forbidden. The QME or AME should not talk to the attorneys or the carrier.
When you talk about details of the exam, you must include ALL Parties.
EXCEPTION for routine matters such as confirming appointments or that records have been sent, etc.
In cases made Permanent & Stationary prior to 01/01/05, the PD (permanent disability) rating is based upon:
Subjective factors of disability, objective factors and work restrictions/preclusions.
Now we use AMA 5th Ed. Guided for whole person impairment (WPI%)
Give objective findings examples
Lab tests, electrodiagnostic testing, x-rays and other imaging
Who may perform a comprehensive medical-legal evaluation and report for the purposes of proving or disproving a contested claim?
PTP
QME
AME
Medical-legal testimony means expert testimony provided by a physician at:
A deposition or
testimony WCAB hearing
Just FYI
‘Types of Causation’
Direct Causation: The work exposures are directly responsible for the health outcomes
Contributing Cause: Several factors led to the disease; work exposure is one of these factors
Acceleration: The disease process is accelerated by virtue of work exposure. The date of onset of the disease is much sooner than would have occurred absent in the
absence of the exposure
Precipitation: The work exposure “precipitates” the manifestation of the illness. For example, an underling tendency or asymptomatic problem was present, but the work exposure causes it to clinically manifest
Aggravation: A medical condition may be present already, but work exposure makes it worse
Define IMR
Independent Medical Review, a record review of patient to determine treatment issues.
Presumptions
presumptions for some injuries and employment
presumption that the injury is accepted if the employer does not deny liability within a prescribed time period of receipt of the claim
New Injury
How much time does an employer have to provide the employee with a DWC1 form for a new claim?
1 business day
What is the timeframe for an employee to file a WC claim to receive benefits?
within 30 days of DOI
By when must an objection to a medical determination by a treating physician be made?
within 20 days of PTP report receipt if represented, 30 days if unrepresented
When can a claims admin submit a QME form 105?
if employee has not submitted the form within 10 days after the form was given to him/her by the employee
If the request for a panel QME is not issued within ____ working days in an unrepresented case the employee can obtain an evaluation from any QME in the area.
20
How many days does the unrepresented worker have to select a physician and make an appointment after the panel is issued before the claims administrator can do so?
10
How many days do the claims administrator/represented worker have to strike a name from a panel?
10
Within how many days must a QME make an appointment with an employee?
Within 90days of initial request, can be extended to 120 days with written request. If not scheduled within 90 days, a new QME Dr. panel can be requested.
How many days does the QME have to submit the QME appointment notification form (form 110)? What info must it include?
5 business days; if an interpreter is needed
Once scheduled, A QME appointment cannot be cancelled less than _____ days by any party without good cause; if cancelled, it but be rescheduled within _____ calendar days and cannot be more than ___ calendar days from the initial request unless agreed upon
6 business days; 30; 90
What is the process for sending records to a QME?
records must first be served to the opposing party 20 days before it is provided to the QME; if the opposing party objects to sending non-medical records within 10 days of its receipt, it will not be provided to the QME
How long do parties have after an appointment to get requested records to QME before QME is allowed to finish report without them? How long does QME have to finish report, regardless of records received?
10 days; 30 days
How long does a QME have to identify a conflict of interest?
5 days from becoming aware of the conflict. For example the person was a former patient, family member, etc.
What is the minimum allowable facetime for a QME exam for a neuromusculoskeleton evaluation?
20 minutes
For how long can a QME be unavailable? When does that QME need to notify the Medical Director of that fact?
14-90 days; 30 days prior
How long does a QME have to complete supplemental reports?
60 days from written notice
By when must workers temporary disability payments after employers knowledge of the claim (unless the employer contests the claim)
14 days
How long does a PTP have to file a doctors first report
5 days
How long does a physician have to contact a local health officer for suspected or diagnosed pesticide poisoning?
24 hours
How many days does an employer have to contest a work comp claim?
90
When a QME receives a request to schedule an evaluation, the QME must issue a QME Appointment Notification Form to all parties within
5 working days
A QME must retain QME reports for how many years?
5
Temporary disability benefits/payments from 2005 forward can last for:
104 weeks
When an IW contacts a QME to make an appointment, the QME must set the appointment within how many days of the contact?
60 days
Within how many days, does the PTP have to send the Doctor’s First Report of Occupational Illness or Injury to the involved parties?
5 days of the initial examination
The ‘QME Appointment Notification Form’ should be sent:
Within 5 business days after scheduling the patient for the evaluation
A PQME or Agreed PQME who cancels a scheduled appointment shall:
Reschedule the appointment within 30 calendar days
QME has to schedule a deposition within .. days.
120 days. It takes place w/in 20 miles where IW’s eval took place.
Temporary disability may last up to… week within … years from the DOI for injuries from 1/1/2008
2 years (104 weeks) , 5 years
Employers who contract with HCO can direct tx of IW up to … days.
90 or 180 days following an injury.
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
QME may be denied reappointment if she was made unavailable for more than… days during a calendar year.
90 days
QME can apply for an extension on a 30 day after appointment report deadline in cases of good cause (medical emergency, natural disaster etc) - how long is the extension?
15 days
Employee has … years to use Supplemental Job Displacement Benefit (SJDB) or within … years of DOI.
2 years or 5 years.
Employer has … days to give return to work dater after the Return To Work (RTW) and voucher report.
60 days.
Supplemental reports must be completed and served no later than…. days since the request.
60 days from the request.
Supplemental report deadline may have extended for no more than… days.
30 days if agreed by both parties.
The re-scheduled appointment date may not be more than … calendar days from the date of the INITIAL request (unless parties agree in writing).
60 days
In how many days after the PTP’s report, shall 2nd opinion spine report be served to all partied?
45 days
IMR decision must be provided to all parties in layterms within how many days of the receipt of the request for review?
30 days and 72 hrs for expedited request
To get the money, IW has to tell the boss about the injury within … days of injury.
30 days
When UR is RETROSPECTIVE, decisions must be communicated to PTP who requested med. services and IW/his lawyer within… days.
30 days
If employer doesn’t provide a new PTP within … days, then IW can choose one himself.
30 days
* normally within 5 days boss should provide a new PTP if IW requests.
Unrep IW. If request for QME panel is not issued within … working days, then IW can have eval from any QME within reasonable geographic area.
20 days
Either party may object PTP’s med. determination by notifying the other party in writing in how many days?
rep vs unrep IW
represented IW- 20 days
unrepresented- 30 days
PTP says IW is P&S. PTP must report within how many days from the date of exam all info about perm. impairment & any need for med. Tx?
20 days unless good cause
Before 1 party can give any info to the QME/AME they must send it (give the heads up) to the other party within… days before info is sent to QME.
20 days
PTP must report results of consults, results of other Drs reports or changes in IW condition in … days after receiving them.
20 days
Within …. days of the Request for Authorization, the UR decision must be made.
14 days. If no additional info submitted within 14 days from the date of submission, then request will be denied.
IW files Request for Factual Correction of QME report, the QME panel has:
… days after request to review corrections and determine if factual corrections are necessary for unrep IW and
….days for both parties or claims admin.
10 days for unrep and 15 days for rep IW or if the request was filed by the both parties or the claims admin.
Represented IW. If IW & boss disagree w/PTP’s findings, they must wait…. waiting period and… for mailing an objection before DWC can assign a QME.
10 days waiting period
5 days for mailing an objection
How many days for each party to strike out 1 QME name from the panel?
If they don’t, then another party choses a QME.
3 days
Represented IW. If no AME agreed upon, then IW has …days to choose a QME.
10 days
A represented IW has…. days to select an AME.
This can be extended if agreed upon for… days.
10 days
20 days
If unrepresented IW doesn’t make a choice of his QME in … days then the insured can make this choice for him in ….days.
10 days and 10 days
If the opposing party objects to sending non-medical records (video tape etc), they need to object how fast so that QME will not be provided the tape?
Within 10 days
Dispute about spinal surgery is NOT handled by QME/AME but a special procedure.
If boss disagrees with needing a sx, insurer (IW) has …. days from the report to disagree. (with the boss)
Both lawyers can agree on a surgeon for a 2nd opinion. If they can’t agree in … days, then AD will provide randomly selected surgeon for a 2nd opinion in … days. If boss/insurer disagrees w/ 2nd opinion–> go to court.
10 days
10 days
5 days
How much in advance should QME notify medical director of being unavailable to perform or schedule an eval?
30 days before the period of unavailability
QME has to let MD (medical director) know of being unavailable to schedule or perform medical eval if QME is unavailable for how long?
14-90 days max
Employer has …. days from the notification of the injury to contest the claim. If he doesn’t, the injury is compensable.
90 days
Temporary Disability Benefits payments must begin within…. days of the employer’s knowledge of the claim
14 days (unless the employer contests (objects) the claim.
Once scheduled, an appointment can not be canceled by QME or any party in ….day, except for good cause.
6 biz. days
A concurrent or prospective Utilization Review REQUEST must get a yes or no decision in… how many days after being received by an adjuster?
5 working days
PTP must be informed by phone/fax in 24 hrs
After employer learns of an injury, how soon should they complete “Employer’s First Report” Employer’s Report of Occupational Injury or Illness?
5 days
Decisions for expedited Utilization Review are made in…
72 hrs (after the receipt of written information reasonably necessary to make a decision)
After employer learns about an injury (from any source), he must provide IW Employee’s Claim for WCB claim (DWC1) within…
1 working day. It must be dated. IW fills it out & returns to boss
PTP must be notified that his request for authorization prior or concurrent with provision of med care is approve is..
24 hrs
Employer must immediately report to OSHA a serious injury in more than ….hrs of hospitalization except obs, loss of body part or disfigurement
24 hrs
How many hrs/days does the employer have to get a PTP from their MPN once they learn of an employee injury?
24 hrs
What is the rule of exclusive remedy?
Worker cannot pursue other civil action, even if employer was negligent, unless the employer is uninsured for work comp
By what percentage is the employee’s compensation increased if an injury resulted from serious and willful misconduct of an employer?
50%
What are the 7 exceptions to claiming something as a work related injury?
- if etoh/drugs were used; 2. intentionally self inflicted harm 3. suicide 4. injury from an altercation in which the employee is an aggressor 5. injuries from a crime 6. injuries during off duty recreational activities 7. psych injuries claimed after termination
For injuries that result from serious and willful misconduct of an injured employee, benefits are reduced by ____ unless_____
50%; unless death or permanent disability of >70%, age <16, or injury resulted from failure of employer to comply with health/safety laws
When first aid is administered, what reports should be filed
Doctors first report (employers first report is not required)
Employers have an obligation to authorize up to $________ within 1 working day after a claim is filed
$10,000
Which 6 components should be included in an occupational history
- all jobs worker has held; 2. length of employment; 3. specific job duties; 4. how much time was spent on each task 5. occupational hazard exposures; 6. what protective equipment was used
What are the 7 exceptions to claiming something as a work related injury? (logical, just think about it)
- if etoh/drugs were used; 2. intentionally self inflicted harm 3. suicide 4. injury from an altercation in which the employee is an aggressor 5. injuries from a crime 6. injuries during off duty recreational activities 7. psych injuries claimed after termination
In which conditions in firefighters, forestry officers, peace officers and correctional employees is the burden of proof on the employer?
hernias, pneumonia, TB, heart dz, cancer
When is a psych injury compensable? “burden of proof”
employment events contribute >50% to injury (or >35% if a violent act was witnessed example Bank Robbery)
When are psych injuries not compensable?
if worker has worked there <6 months in total, if claim is due to personnel matters, or if claim is filed after notice of termination (except in extreme cases)
After how many visits can a chiropractor no longer be the treating physician
24
For injuries occurring after which date are the AMA guides used to evaluate disability?
1/1/2005
What event generally triggers a QME evaluation under LC 4061
permanent disability dispute after the PTP claims worker is P&S and termination of temporary disability
What is a QME evaluation under LC 4060
Helping to determining the compensability of a claim after claim form is filed but before the body part has been accepted by the claims administrator
What disputes fall under LC 4062?
- is worker temporarily disabled? 2. does worker need work restrictions? 3. is there a new/further disability after judicial determination of permanent disability as a result of injury deterioration 4. whether a new body part added to the claim
Since when has disputes over what medical treatment not done by QMEs
since 7/1/2013–now resolved by IMR process if UR is denied
What is the difference between QME forms 105 and 106?
105–unrepresented workers; 106–represented workers
who gets the first opportunity to request a QME panel?
injured worker
Can a worker get a second med-legal evaluation if they later become represented by an attorney?
No
QME evaluations are only available for represented workers for DOI after______?
1/1/2005
Can an evaluator cancel an appointment for lack of medical records?
No (unless psych)
The April 1997 Permanent Disability Rating Schedule (PDRS) can be used for a DOI prior to_____?
1/1/2005
Now we use the AMA Gides 5th Ed for Whole Person Impairment %
How can an unrepresented worker ask for a factual correction to a QME report?
File form QME 37, asking the QME to correct facts; The QME has 10 days to do so.
What is the process for sending records to a QME?
records must first be served to the opposing party 20 days before it is provided to the QME; if the opposing party objects to sending non-medical records within 10 days of its receipt, it will not be provided to the QME
Which records are prohibited from being sent to a QME?
1, any prior report that has been rejected as untimely; 2. an MD report that talks about impairment/disability that is not by a PTP, secondary physician, or QME (unless judge rules it admissible) 3. Any record that has been stricken by a judge
How much $ does a worker receive for total disability?
weekly amount that was determined for temporary disability for life
If the Injured Worker can NOT return to their job, they are a QIW (Quilified Injured Worker) and get $ to retrain called: Supplemental Job Displacement Benefits (SJDB), PAY OUT AMOUNTS
For injuries before 1-1-13 the voucher amount ranges from $4000 to $10,000 depending upon the permanent disability rating
For dates of injury on/after 1-1-13 the voucher will be $6000 across the board, regardless of the permanent disability rating
The voucher will be due 60 days after a treating doctor, AME or QME declares the injured worker permanent and stationary, reports what the worker’s work capabilities are
and the employer does not offer the worker a job
If offered, the job must pay no less than 85% of the worker’s earnings at the time of the injury, and be expected to last at least 12 months
The SJDB voucher can be used for?
Training at a California public school, or other approved provider listed by the state
To pay for licensing or certification and testing fees
Purchase tools required by a training course
Up to $1000 to purchase a computer and/or $500 in miscellaneous expenses
Up to $600 for the services of a licensed placement agency or vocational counselor
What are the voucher amounts for supplemental job displacement benefits?
PDRS<15% $4000; 15-25%: $6000 26-49%: $8000; 50-99%: $10,000
How much $ does a worker receive for partial disability
weekly payments for a number week weeks determined by employer’s disability rating and a small pension for life if >70% disability
Who qualifies for SJDB. Vouchers? What amount?
Employees injured on or after 1/1/04 whose employers do not provide alternative work; amount is $6000 if injured on or after 1/1/2013 and varies based on disability level for 1/1/04-12/31/12
How much voucher $ can be used for vocational and return to work counseling?
up to 10%
Can a physician determine disability?
No. QME determines impairment rating
When does the physician calculate the disability rating?
Never (the physician provides an impairment rating only and apportionment)
What 2 additional things go with a PR-4 report?
- Description of any permanent impairment; 2. RTW and voucher report for any permanent partial disability
What is one of the best treatments for delayed recovery and chronic pain?
CBT Cognitive Behavioral Therapy
What are the only reports a judge can use to make a permanent disability award for an unrepresented worker?
QME, AME and PTP reports
Are AMEs regulated by the DWC?
No
What can happen to a QME if they don’t report people who helped put together the report?
Termination as a QME
What must a QME inform an unrepresented worker of at the beginning of the evaluation?
worker’s rights to ask questions regarding the evaluation process and about the evaluator’s background
When can chronic pain be considered ratable?
- if the symptoms/exam match a known medical condition 2. if the presentation is typical of the diagnosed condition and 3. if the diagnosed condition is widely accepted by a pathophysiologic basis
Note: QME can add upto 3% WPI for Pain
when pain is considered unratable, what does that really mean?
QME is unable to determine how the activity restrictions are linked to disease or injury
If rating a pain related impairment, what 2 things must a physician do to rate?
- increase WPI by up to 3% and classify the impairment into mild, moderate, moderately severe or severe
What is the rule about modified/alternative work that an employer provides after a worker is P&S for DOI btw 1/1/05 and 12/31/12
If an employer with > 50 employees fails to provide alternative work within 60 days of an employee becoming P&S, disability payments increase by 15%; if they are able to provide it, payments decrease by 15%
An IW having had 3 similar jobs at 3 different employers, but realized she had a problem/injury of a cumulative nature while working for the most recent employer would place liability for any resultant disability/impairment on:
A. The most recent employer with WC insurance
B. The employer where the problem/injury first began
Which of the following specialties/disciplines are prohibited from writing a medical legal report in a case where impairment/disability is being disputed:
Acupuncture - Can complete the entire report except the impairment rating
Cases involving work acquired HIV/AIDS involve confidentiality for the IW that involves:
Normal medical confidentiality laws
The maintenance of a fictitious name file maintained by a WCJ
A QME or AME must address all disputed issues in a claim with the exception of…?
Medical treatment disputes are now done by an IMR
Which of the following can a QME or AME not do with regard to the IW being evaluated?
QME can NOT provide treatment on that day, unless it is a medical emergency
If impairment for a given condition is not listed in the AMA Guide (5th Ed.), the evaluator may use an impairment value for a listed condition that more accurately characterizes the IW’s impairment, as long as it:
Is contained within a chapter of the AMA Guide 5th Edition
(Almaraz Guzman Rule)
An Information & Assistance Officer can talk to a represented IW, an unrepresented IW and anyone else.
True
Secondary erectile dysfunction, sleep disorders and/or psych disorders that are a
compensable consequence of the primary injury for 1.1.13 injuries and forward are
Treatable under the claim but not ratable with regard to disability/impairment
Ratable if catastrophic in nature
When measuring extremity joint ranges of motion (ROM) in cases made permanent & stationary prior to 2005, which standard normal values are used?
Packard Thurber’s ‘Estimated Average Normals’ 1960
Can an IW tape record the QME examination?
Yes
When evaluating an injured extremity in a 2010 case, the evaluator must do which of the following?
Compare findings to normal values in the AMA Guide (5th Ed.)
Compare findings to the opposite, un-injured extremity
Does a QME need authorization to refer out an IW for medically reasonable and necessary consultations and/or diagnostic testing?
Yes
If any IW self-procures an evaluation from a doctor who is not the PTP or the QME, which of the following is true?
The PTP or the QME must issue a supplemental report commenting on the self-procured report
The self-procured report is inadmissible
Temporary disability benefits normally cannot be paid for longer than 2 years (104 weeks), unless the injury involves which of the following?
Severe burns
Chronic lung disease
Amputation
The time that the injured worker spends with an interpreter can be calculated as the doctor’s face to face time with the patient when?
No. The doctor is face to face with the injured worker interacting
Medical research involves investigating medical issues by reading medical and scientific journals and texts. It does not include reading or reviewing which of the following?
AMA Guides for the Evaluation of Permanent Impairment
Treatment guidelines (ACOEM – MTUS)
Labor Codes
California Code of Regulations
The QME/AME is permitted to talk to whom?
PTP
When the PTP writes a permanent and stationary (P&S) report it is not considered a medical-legal report, unless
The claim is contested or disputed
‘Physician’s office’ means a bona fide office facility which is identified by a street address and any other more specific designation such as a suite or room number and which contains the usual and customary equipment for the evaluation and treatment appropriate to the physician’s medical specialty or practice. Which does not apply?
Post Office Box
Parking lot
Home
Retail store
The injured worker may discontinue the evaluation based on good cause, including:
Discriminatory conduct toward the worker based on race or sex
Discriminatory conduct toward the worker based on religion or sexual preference
Requests for the worker to submit to unnecessary examination or procedure
Abusive, hostile or rude behavior toward the worker that demonstrates bias
Benefits available to the injured worker are:
Medical treatment
Temporary disability payments
Permanent disability payments
Vocational rehabilitation services Death benefits
In cases involving physical injury for 1.1.13 dates of injury and forward, injured workers will not be able to collect additional permanent disability for sleep disorders, sexual dysfunction, or psych injuries that did not directly result from those injuries. QME/AMEs and PTPs will not be able to comment on permanent disability add-ons for which conditions, however, can discuss need for treatment:
Sleep disorders
Sexual dysfunction
Psychological issues, unless the physical injury is ‘catastrophic,’ or where the injured worker was the victim of a violent act or a witness to a violent act/crime
In the event that no records are received by the QME/AME to prepare and issue a medical-legal report, what do you do?
The QME report must be served within 30 calendar days with or without records
The QME can contact the treating physician to obtain records
The QME should issue a supplemental report when the records are received
When an injured worker does not speak or understand the English language and an interpreter is used in a medical-legal evaluation. What type?
Only a Certified interpreter. Include name and certification number in the report
No AME or QME shall accept gifts that have a total fair market value in the aggregate of _____ for more, from any single source that handles California workers’ compensation matters, in the course of any consecutive 12 months.
$360
The AMA 5th Ed. Guides consider both anatomic and functional loss in evaluating impairment.
Anatomic loss refers to damage to an organ system or body structure
Functional loss refers to a change in function for the organ or body system
Impairment criteria contained in the Guides provides a standardized method for physicians to use to determine medical impairment
The impairment criteria in the Guides were developed from scientific evidence and from consensus of chapter authors or of medical specialty societies
For dates of injury before 2005, Subjective Factors of Disability are used to determine frequency of symptoms/complaints. Define Occasional, Intermittent, Frequent & Constant based on %.
Occasional pain occurs approximately 25% of the time Intermittent pain occurs approximately 50% of the time
Frequent pain occurs approximately 75% of the time
Constant pain occurs approximately 90 to 100% of the time
For dates of injury before 2005, Subjective Factors of Disability are used to determine intensity of symptoms/complaints. Define Mild, Slight, Moderate & Severe Pain.
Minimal (or mild) pain would constitute an annoyance, but would cause no handicap in the performance of a particular activity and is non-ratable.
Slight pain can be tolerated but would cause some handicap in the performance of the activity precipitating the pain.
Moderate pain can be tolerated, but would cause a marked handicap in the performance of the activity precipitating the pain.
Severe pain, would preclude the activity precipitating the pain.
Permanent Disability reports for musculoskeletal injuries for dates of injury before 2005 take into consideration for rating purposes, which of the following?
Subjective Factors of Disability
Objective Factors of Disability
Work Preclusions or Restrictions
If employer doesn’t provide a return to work DATE 60 days after the RTW and voucher report, then what kicks in?
Supplemental Job Displacement Benefit (SJBD).
6K. 1K towards computer. The rest is resume, job search, exam fees etc.
3 reasons for ineligibility for IMR:
- didn’t submit IMR application within 30 days of adverse UR determination
- didn’t sign IMR application
- dispute reg. liability
If the employer doesn’t have an MPN & didn’t provide a new PTP within 30 days, then IW can chose their…
personal chiro or acupuncturist if they are pre-designated. . Otherwise boss has control over 1st 30 days of who the PTP is.
Temporary disability is not paid for IW for …. (hrs/days) unless they are hospitalized/miss work for more than 14 days
3 days
what is the relationship between injury, disability and causation
cause=>injury=>disability
What 3 factors need to be established in order to make a causation determination
- what is the injury/disability 2. what relevant work exposures were present 3. what other causes might produce the disease (non-industrial exposures)?
What are the 5 types of causation?
- direct causation 2. contributing cause 3. aggravation 4. precipitation 5. acceleration
What should an evaluator do if there are conflicting accounts of the injury regarding causation?
opinion should be expressed conditionally in each of the possible scenarios
What are QMEs supposed to apportion?
disability, not injury. QMEs may also not apportion to risk factors (eg. gender/age, although can apportion to pre-existing medical conditions)
What type of disability does apportionment apply to?
Permanent disability
Apportionment can only be based on which of the following?
Causation of the permanent disability
List the 3 fee schedules
QME/AME-Medical Legal Fee Schedule (MLFS)
Treatment - Official Medical Fee Schedule
If an AME or an agreed panel QME is used to evaluate a case, which of the following applies to the amount that can be charged for their medical-legal services?
25% more than the regular ML charge (for example ML 102-94)
A medical legal expense under LC4662 must be paid within how many days?
60
Medical-legal expense means any costs or expenses incurred to:
Prove or disprove a contested claim
Comprehensive Medical-Legal Evaluation ML-201
Includes an initial evaluation
Includes a follow-up evaluation that is 18 months and one day later than the last evaluation. $2,015.00 plus $3.00 per page of review in excess of 200 pages
A Follow Up Medical-Legal Report (ML 202) involves the following:
An evaluation that occurs within 18 months of a prior comprehensive evaluation.
Records previously reviewed are excluded from payment.
$1,316.25 plus $3.00 per page in excess of 200 pages not previously reviewed
Served within 30 days
A Supplemental Medical-legal Report (ML 203) involves the following:
Does not involve examination of the injured worker
Only refers to a request for a supplemental report if the physician failed to address an issue previously requested or a new development occurs
$650.00 plus $3.00 per page after 50 pages
The 50 pages and any additional pages were not previously reviewed
Preparing a narrative report.
Must be served within 60 days
Medical-Legal testimony ML-204
$455.00 per hour with a minimum of 2 hours ($910.00)
Missed appointment ML-200
$503.75
The physician can bill for a record review report if the records were received and reviewed in connection with a missed appointment
Sub rosa review ML-205
$325.00 per hour plus report associated with writing the review
Modifiers – Applies only to Comprehensive Medical-Legal Report, Follow-up Medical-Legal Report, and Supplemental Medical-Legal report
Multiple Bill x Modifier
Modifier 93 Interpreter = 1.1
Modifier 94 AME Modifier = 1.35
Modifier 96 is for psychiatrist or psychologist = 2.10
Modifier 97 Toxicology = 1.5
Modifier 98 Oncology = 1.5
example AME and Interpreter Modifiers combined = 1.45
A physician can bill for time spent reviewing their own records in preparation for the deposition (True/False)
TRUE
If a worker suffers an injury and the employer is uninsured, the employer is responsible for all bills related to the injury or illness. (True/False)
TRUE
The Uninsured Employers’ Benefit Trust Fund (UEBTF), a special unit within the DWC may pay benefits to injured workers who get injured or ill while working for an illegally uninsured employer. The UEBTF pursues reimbursement of their expenditures from the responsible employer through all available avenues, such as filing a lien against their property. (True/False)
TRUE
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
2002
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.
No
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.
1%-3% whole person impairment
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:
Headache pain can be given an impairment rating of between 1%-3% WPI
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
Apportionment applies because it is presumed that a prior PD for the same body part is permanent and still exists.
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?
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
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
AOE - The injury arose from employment but did not occur during the course of
employment
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:
There was no industrial causation because a normal commute to and from work is not considered to be AOE or COE
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?
The QME must disclose the relationship on a financial conflict of interest form with the AD before proceeding with the referral
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
The QME spent less than 20 minutes face-to-face time evaluating the IW with no explanation and did not provide a report
Which of the following is not a routine Activity of Daily Living, per the AMA Guide to the Evaluation of Permanent Impairment (5th Ed.)
Ability to work
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:
The routine Activities of Daily Living which everyone must do irrespective of their job
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:
A reasonable accommodation
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:
Panel QME
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:
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
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:
Considered a minor first aid incident with no claim filed
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?
No impairment rating should have been given for pain with a 0% rating
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?
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)
An IW who is being accommodated by their employer with modified work duty should receive temporary disability compensation only if the following is true:
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
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.
True
If a person reviews the records for a QME for purposes of organizing and consolidating the records, it is considered:
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
If a QME contacts the PTP to gather more information, ask questions or inquire about records, it is considered to be:
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
Can an IW request to see the QME’s curriculum vitae, license or QME certificate at the time of the face-to-face evaluation?
Yes
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?
Only parties in a represented case
Only an unrepresented injured worker
Only the insurance carrier’s claims adjustor
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?
Never. It is always a conflict of interest
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?
DEU
In an unrepresented case, if the DEU has not issued a summary rating determination, where should a QME’s supplemental report be sent to?
A supplemental report should not be issued until a determination is made
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?
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
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?
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
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?
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
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:
The panel QME was agreed to and can charge 25% more for their QME services
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?
Under SB899, all cases made permanent & stationary after 2005 are rated using the AMA Guide (5th Ed.) impairment rating system
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?
1 working day
A QME may perform a medical-legal evaluation in which situations?
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
P&S means that residual impairment or disability exists (True/False)
FALSE, there may be impairment or no impairment
Discharged as cured means the condition has resolved (True/False)
TRUE
Pre-injury status means the condition has resolved (True/False)
TRUE
The standard to prove causation is not medical certainty, but a reasonable medical probability (True/False)
TRUE
Any doctor/acupuncturist who has treated the worker cannot be the QME (True/False)
TRUE
Is there a limit to temporary disability benefits (TTD)?
Yes, 2 years
A QME or AME should not:
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
How long does Future Medical care last?
Forever.
Per Labor Code 4600 what medical/hospital treatment is provided by the employer?
Medical, chiropractic, surgical and acupuncture care
Hospital treatment including nursing
Medicines, medical and surgical supplies
Crutches, apparatuses, including orthotic and prosthetic devices and services
In the California Workers’ Compensation System, a physician is?
M.D., D.C., D.O.
D.P.M, Ph.D., D.D.S.
L. Ac., O.D.
Impairment is considered permanent when it has reached MMI (True/False)
TRUE
Permanent and stationary (P&S) means that the condition will never change (True/False)
TRUE
Which reports are admissible at the WCAB?
Reports from the PTP
Reports from the QME or AME
100% total disability is presumed to exist in which of the following injuries?
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
QMEs are limited to 10 locations to evaluate injured workers (True/False)
TRUE
QME panels are picked within geographic region of the worker’s home residence OR work (True/False)
TRUE
In which of the settings below must interpreting services, be provided to an injured worker who does not speak or understand English?
A deposition
Appeals Board hearing
Medical-legal examination
Medical treatment appointment
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)
TRUE
Each new PTP must complete a Doctor’s First Report of Occupational Injury or Illness (Form DLSR 5021) following the initial examination. (True/False)
TRUE
Medical treatment is designed to cure or relieve the effects of the industrial injury. (True/False)
TRUE
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)
TRUE
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)
TRUE
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)
TRUE
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)
TRUE
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.
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
CC&R 9768.10 indicates that IMR doctors can be an MD, DO or DPM. (True/False)
TRUE
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
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
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
A QME may obtain a consultation from any physician as a reasonable and necessary expense. (True/False)
FALSE
The evaluator and the employee’s treating physician(s) may consult as necessary to produce a complete and accurate report. (True/False)
TRUE
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
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
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
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
“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
“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
“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
“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
An employee shall have no more than 1 primary treating physician at a time. (True/False)
TRUE
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
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
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
In unrepresented cases an AME cannot be used. (True/False)
TRUE
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!!!
The term impairment in the AMA 5th Ed. Guides refers to permanent impairment. (True/False)
TRUE
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
The final impairment rating should be rounded to the nearest whole number? (True/False)
TRUE
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)
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
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
For psychiatric injuries, impairment is not decided by the AMA Guides, but the Global Assessment of Function (GAF) Scores. (True/False)
TRUE
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
A permanent disability report is for a date of injury before 2005. (True/False)
TRUE
A permanent impairment report (AMA) is for a date of injury from 2005 and forward. (True/False)
TRUE
Ratings are adjusted for age and occupation. (True/False)
TRUE
Temporary disability payments cease when the worker returns to work, or is P&S. (True/False)
TRUE
A 1 to 3% add-on rating for pain can only be added if there is a ratable impairment. (True/False)
TRUE
A QME must see the worker within 90 days of the request for an appointment. (True/False)
TRUE
A QME may see the patient after 90 days by agreement of the scheduling party, however, not beyond 120 days. (True/False)
TRUE
The QME Appointment Notification Form (Form 110) shall be submitted within 5 business days. (True/False)
TRUE
An oral cancellation of a QME appointment must be followed by a written confirmation. (True/False)
TRUE
All communications with a QME must be in writing. (True/False)
TRUE
QMEs do not resolve treatment disputes; the IMR process resolves them. (True/False)
TRUE
A QME shall advise the injured worker before the examination that he/she is entitled to ask the evaluator questions. (True/False)
TRUE
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
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
To constitute substantial medical evidence, a medical opinion must be predicated on reasonable medical probability. (True/False)
TRUE
QME reports shall be kept for 5 years from the date of each evaluation report. (True/False)
TRUE
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
Chiropractors are required to take a 44 Hour California Workers Compensation Evaluation Course or have completed a 300-hour postgraduate specialty program. (True/False)
TRUE
A psychologist must have at least 5 years postdoctoral experience in the treatment of emotional or mental disorders. (True/False)
TRUE
All physicians must have completed at least a 12 Hour Disability Evaluation Report Writing Program prior to appointment as a QME (Except DCs - 44 Hour Course includes Report Writing) (True/False)
TRUE
The State of California uses the most current edition of the AMA Guides to determine impairment.
(True/False)
False - Only the Fifth Edition
The AMA Guides - Fifth Edition are only used for dates of injury 1-1-05 and forward. (True/False)
TRUE
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)
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
An AME must be a QME. (True/False)
FALSE. Any Dr can be an AME
Are Secondary physician reports, accepted at the WCAB?
NO
Are Secondary physician reports, adopted by the PTP accepted at the WCAB?
YES
A QME who has treated the injured worker, must disqualify them self if their name appears on the QME panel list. (True/False)
True
The DWC - Medical Unit is responsible for providing panel QME lists. (True/False)
True
Medical-legal testimony means expert testimony provided by a physician at a deposition or WCAB hearing. (True/False)
True
An interpreter shall be provided if the injured worker does not proficiently speak or understand the English language. (True/False)
True
Medical-legal testimony means expert testimony provided by a physician at a deposition or WCAB hearing. (True/False)
True
An interpreter shall be provided if the injured worker does not proficiently speak or understand the English language. (True/False)
True
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
Request for Authorization (RFA) is used to request treatment in a work comp claim. (True/False)
True
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
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.
To add up to 3% whole person impairment for pain (Chapter 18), no formal assessment of pain-related impairment is required. (True/False)
True
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
A permanent impairment rating should not be provided until the patient is permanent and stationary/MMI. (True/False)
True
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
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
ADDING VS COMBINING (CVC TABLE)
Adding results in a HIGHER WPI.
Combining, compressed and lowers the WPI. (True/False)
TRUE
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.
The QME must include face-to-face time with the applicant/patient? (True/False)
TRUE
If P&S, fill out and submit DWC AD Form 10133.36 (SJDB) Physician’s Return-to-Work & Voucher Report (True/False)
TRUE
Case Law
Escobedo v. Marshalls
substantial medical evidence
Case Law
Yeager Construction v. Workers’ Comp. Appeals Bd.
substantial evidence is reasonable medical probability
Employers who contract with HCO can direct tx of IW up to … days.
90 or 180 days following an injury.
QME has to schedule a deposition within .. days.
120 days. It takes place w/in 20 miles where IW’s eval took place.
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
In how many days must QME hand in her report after an exam/appointment ?
30 days
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.
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.
IF QME has to cancel scheduled app, she must tell the parties in writing the reason and reschedule within ….days of cancelation.
30 days
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
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
CME for QME is ….. hrs in …years
12 hrs in 2 years. Passing QME is 6 hrs
