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Trove California QME Flashcards > QME Deck 1/2 > Flashcards

QME Deck 1/2 Flashcards

Competency Exam

1
Q

What was a significant reason workers’ compensation systems were established in the early twentieth century in the U.S.?

A

To prevent the need for employees to prove employer negligence in court

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2
Q

What was the primary purpose of the Boynton Act of 1913?

A

To require most employers to provide workers’ compensation coverage

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3
Q

Which act replaced the Boynton Act in 1917 and included provisions for considering an employee’s diminished ability to compete in the labor market?

A

The Workers’ Compensation Insurance and Safety Act

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4
Q

What does the “No Fault” rule in the workers’ compensation system imply?

A

Employers are required to provide benefits regardless of who caused the injury, Employees cannot file for workers’ compensation if they were aware of the risks

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5
Q

Under the “Historic Compromise,” what is one benefit that employees give up in exchange for prompt workers’ compensation benefits?

A

The right to file a civil suit for damages

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6
Q

Which of the following is NOT a component of the “Historic Compromise” in the workers’ compensation system?

A

Unlimited Compensation

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7
Q

What happens to workers’ compensation benefits if an injury results from the serious and willful misconduct of the employer?

A

Benefits are doubled

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8
Q

What changes were introduced by the measures enacted in 2003 and 2004 regarding medical treatment?

A

Allowed employers to establish medical provider networks and limit certain treatments

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9
Q

Which of the following is an exception to the “No Fault” rule under California workers’ compensation law?

A

Deliberately self-inflicted injuries

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10
Q

What was one of the major changes introduced in 2013 to California’s workers’ compensation system?

A

Introduction of independent medical review for treatment disputes, Elimination of medical provider networks, Reducing the amount of compensation for temporary disabilities

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11
Q

Which of the following individuals is NOT associated with the Department of Industrial Relations?

A

Jose Garcia,

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12
Q

What is the primary mission of the Division of Workers’ Compensation (DWC)?

A

To minimize the adverse impact of work-related injuries on California employees and employers,

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13
Q

Which unit within the DWC is responsible for conducting audits to ensure compliance with the Labor Code and DWC regulations?

A

Audit and Enforcement Unit,

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14
Q

What does the Disability Evaluation Unit (DEU) primarily determine?

A

Permanent disability ratings,

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15
Q

Which unit provides assistance to employees, employers, and other parties regarding rights and benefits under California’s workers’ compensation laws?

A

Information and Assistance (I&A) Unit,

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16
Q

What is one function of the Workers’ Compensation Appeals Board (WCAB)?

A

Reviewing Petitions for Reconsideration of decisions made by Workers’ Compensation Administrative Law Judges,

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17
Q

Which unit is responsible for overseeing medical provider networks and handling complaints against Qualified Medical Evaluators (QMEs)?

A

Medical Unit,

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18
Q

What is the purpose of the Workers’ Compensation Information System (WCIS)?

A

To collect and manage electronic records from claims administrators,

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19
Q

Which fund provides compensation when employers fail to pay workers’ compensation benefits and are illegally uninsured?

A

Uninsured Employers Benefits Trust Fund (UEBTF),

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20
Q

What type of permanent disability ratings does the DEU prepare?

A

Formal, consultative, and summary,

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21
Q

The Medical Unit under the DWC is involved in which of the following activities?

A

Certifying and overseeing medical provider networks (MPNs),

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22
Q

Which unit is tasked with assisting in the resolution of disputes and complaints related to workers’ compensation claims?

A

Information and Assistance (I&A) Unit,

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23
Q

Which fund provides additional compensation to workers who had a pre-existing disability that combined with a new injury to result in a permanent disability of at least 70%?

A

Subsequent Injuries Benefits Trust Fund (SIBTF)

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24
Q

What role does the Audit and Enforcement Unit play in the workers’ compensation system?

A

It ensures that insurance companies and self-insured employers meet their obligations under the Labor Code,

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25
Q

Which unit is responsible for examining and appointing physicians to be Qualified Medical Evaluators (QMEs)?

A

Medical Unit,

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26
Q

What is the main function of the Legal Unit within the DWC?

A

To provide legal advice and representation for the DWC,

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27
Q

Which of the following is a responsibility of the Disability Evaluation Unit (DEU)?

A

Preparing permanent disability ratings for use in determining benefits

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28
Q

The Workers’ Compensation Appeals Board (WCAB) consists of how many commissioners?

A

Seven

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29
Q

Which unit handles disputes and complaints related to the Qualified Medical Evaluator (QME) process?

A

Medical Unit

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30
Q

What is the primary function of the Research Unit within the DWC?

A

To analyze and report on data related to the workers’ compensation system

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31
Q

Which unit is responsible for assisting injured workers with understanding their rights and benefits under California’s workers’ compensation laws?

A

Information and Assistance (I&A) Unit

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32
Q

What is the purpose of taking a complete occupational history?

A

To understand all jobs the worker has held, including hazards and protective equipment used

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33
Q

How is a specific injury defined in the context of workers’ compensation?

A

An injury resulting from a single incident or exposure

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34
Q

What is the definition of first aid according to the Labor Code?

A

Any one-time treatment for minor injuries that do not require further medical care

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35
Q

What does the term “arising out of employment” (AOE) refer to?

A

The injury is directly related to the work environment or tasks

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36
Q

What is considered an aggravation of a pre-existing non-industrial condition?

A

An on-the-job incident that worsens a pre-existing condition

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37
Q

In the workers’ compensation system, which of the following injuries is excluded from compensation?

A

Injuries resulting from alcohol or illegal substance use

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38
Q

When determining causation, which of the following is NOT a type of causation?

A

Recurrence

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39
Q

Why is the “date of injury” (DOI) important in a workers’ compensation claim?

A

It determines the statute of limitations for filing a claim

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40
Q

What is required to prove that an injury is work-related?

A

Work activities contributed to the injury to a significant degree

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41
Q

How is a cumulative injury defined in the context of workers’ compensation?

A

An injury that results from repetitive trauma over time

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42
Q

In which scenario would a physician’s report NOT lead to the establishment of a compensable injury?

A

The injury was caused by the employee’s use of illegal substances

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43
Q

What does “occurring in the course of employment” (COE) imply?

A

The injury occurred while the employee was performing job-related duties

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44
Q

Which of the following best describes the role of a physician in the workers’ compensation system?

A

Providing medical opinions that guide claims decisions

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45
Q

What should a physician consider when establishing causation for a cumulative injury?

A

The worker’s medical history and all relevant exposures

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46
Q

How are psychiatric injuries treated differently in workers’ compensation claims?

A

They require a higher standard of proof for causation

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47
Q

What is the purpose of taking a complete occupational history?

A

To understand all jobs the worker has held, including hazards and protective equipment used

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48
Q

How is an injury defined under the workers’ compensation system?

A

Any injury or disease arising out of employment

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49
Q

Which of the following is considered first aid according to Labor Code § 5401(a)?

A

One-time treatment for minor injuries like cuts and burns

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50
Q

What does “Aggravation” refer to in workers’ compensation terms?

A

A temporary or permanent increase in disability due to work

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51
Q

Which of the following best defines “Arising Out of Employment” (AOE)?

A

An injury directly caused by work activities

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52
Q

Which of the following is NOT necessary to establish when determining causation?

A

The workplace location

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53
Q

What is the significance of “Occurring in the Course of Employment” (COE) in workers’ compensation?

A

It involves the circumstances surrounding the accident or exposure

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54
Q

What is a “Presumption” in the context of workers’ compensation?

A

A legal assumption that certain conditions are work-related for specific employee groups

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55
Q

Under what condition is a psychiatric injury compensable according to Labor Code §3208.3?

A

If it is a diagnosed mental disorder with employment being the predominant cause

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56
Q

What happens if a psychiatric claim is filed after notice of termination or layoff?

A

It is not compensable unless specific conditions are met

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57
Q

Which of the following is an example of an “incidental” activity included in the course of employment?

A

Traveling on behalf of the employer

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58
Q

Which of the following best describes the role of a physician in determining AOE/COE?

A

To provide medical evidence regarding the relationship between exposure and injury

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59
Q

What is the threshold for causation in psychiatric injury claims?

A

Employment must be the predominant cause of the injury

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60
Q

Which of the following could be a compensable consequence of a physical injury?

A

A psychiatric injury deriving from an underlying physical injury

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61
Q

Which of the following is true about workers’ compensation for employees who travel on behalf of their employer?

A

They are covered for the entire travel period unless there is a substantial deviation from the agreed route

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62
Q

Who must an employee notify within 30 days if they sustain a work-related injury or illness?

A

Employer,

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63
Q

What form must an employer provide to an employee within one working day of learning about an injury?

A

Employee’s Claim for Workers’ Compensation Benefits (DWC 1)

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64
Q

Which of the following workers is NOT covered under the California workers’ compensation system?

A

Longshore workers

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65
Q

What must an employer do immediately after being notified of a serious injury or death at the workplace?

A

Report to the Division of Occupational Safety and Health (DOSH)

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66
Q

Which party in the workers’ compensation system typically manages the claims and makes key decisions about benefits?

A

Claims Administrator

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67
Q

Who is responsible for ensuring that an employee’s work environment is safe and healthful?

A

Employer

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68
Q

What is the maximum number of chiropractic visits an injured employee can have after January 1, 2004, unless authorized for more?

A

24 visits

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69
Q

Which of the following tasks is typically NOT the responsibility of a claims administrator?

A

Filing legal claims against the employer

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70
Q

What is required for an employee to change their treating physician to a personal chiropractor after a work-related injury?

A

They must provide the employer with the name and address of the chiropractor before the injury occurs

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71
Q

Which document must an employer complete within five days of being notified of an employee’s occupational injury?

A

Employer’s Report of Occupational Injury or Illness (Form 5020)

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72
Q

What happens if an employee does not predesignate a personal physician before sustaining a work-related injury?

A

The claims administrator has the right to select the treating physician within the first 30 days

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73
Q

What is a serious injury as defined by the California workers’ compensation system?

A

An injury resulting in more than 24 hours of hospitalization for something other than observation

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74
Q

Who must provide the employer with written notice before canceling a workers’ compensation policy?

A

Insurance Carrier

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75
Q

Under what circumstances can an injured worker’s attorney receive fees directly from the worker’s compensation award?

A

When the workers’ compensation judge or WCAB authorizes it

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76
Q

What is the primary role of medical case managers employed by insurers in the workers’ compensation system?

A

To assist in medical and other aspects of the case, including attending physician appointments

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77
Q

What must an employer provide to an employee within one working day of learning about an injury?

A

Employee’s Claim for Workers’ Compensation Benefits (DWC 1)

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78
Q

What are Temporary Disability (TD) payments based on?

A

The employee’s average weekly earnings at the time of the injury

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79
Q

How many weeks of Temporary Disability (TD) payments can an injured worker receive if their injury occurred between January 1, 2008, and the present?

A

104 weeks within five years from the date of injury

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80
Q

What type of disability payments are provided to an employee who does not completely recover from an injury?

A

Permanent Disability (P payments

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81
Q

For injuries occurring on or after January 1, 2013, what is the maximum amount of the Supplemental Job Displacement Benefit (SJDB) voucher?

A

$6,000

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82
Q

What happens if an employee with a permanent partial disability does not return to work within 60 days of the termination of Temporary Disability payments?

A

The employee may qualify for a Supplemental Job Displacement Benefit (SJD voucher

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83
Q

Which of the following is covered under Death Benefits in the workers’ compensation system?

A

Burial expenses up to $10,000 for injuries on or after January 1, 2013

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84
Q

What is the purpose of the Return-to-Work Fund?

A

To make supplemental payments to workers whose permanent disability benefits are disproportionately low in comparison to their earnings loss

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85
Q

What is the penalty if an employer discriminates against an employee for filing a workers’ compensation claim?

A

The employer may face legal action and be required to compensate the employee

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86
Q

Who is responsible for ensuring that an injured worker receives appropriate benefits in a timely fashion?

A

The treating physician

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87
Q

What is the maximum amount of burial expenses covered under Death Benefits for injuries occurring before January 1, 2013?

A

$5,000

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88
Q

Which benefit compensates employees who are permanently unable to return to their pre-injury job due to a work-related injury?

A

Permanent Disability (P, Temporary Partial Disability (TP

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89
Q

What must an employer do if they fail to provide the necessary medical treatment within one working day after a claim is filed?

A

Allow the worker to self-procure treatment, with the WCAB retaining jurisdiction over reimbursement

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90
Q

How is the amount of Permanent Disability (PD) payments determined?

A

According to the percentage of disability

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91
Q

What type of disability payments can continue for life after the permanent disability amount is exhausted?

A

A small pension for workers with permanent partial disabilities of 70% or more

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92
Q

What percentage of an employee’s estimated wage loss is covered by Temporary Partial Disability (TPD) payments?

A

66%

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93
Q

What is included in Medical Treatment benefits under workers’ compensation?

A

Interpreter services related to the treatment

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94
Q

Which of the following is NOT covered under workers’ compensation benefits?

A

Income from work outside the regular job

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95
Q

What happens if an employer offers regular, modified, or alternative work to an injured employee within 60 days of the injury becoming permanent and stationary?

A

The employee’s disability payments are decreased by 15%

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96
Q

What is the penalty for an employer that terminates an injured worker during the period of temporary disability without proving a business necessity?

A

Legal action and potential compensation to the employee

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97
Q

Who is primarily responsible for managing the care of an injured worker in California’s workers’ compensation system?

A

Primary Treating Physician (PTP)

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98
Q

Which of the following is a requirement for an MPN in the California workers’ compensation system?

A

Must include a mix of doctors specializing in work-related injuries and general medicine

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99
Q

A secondary treating physician is responsible for:

A

Reporting findings to the Primary Treating Physician (PTP)

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100
Q

What is a Medical Provider Network (MPN)?

A

A network of providers established by the employer or insurer to treat work-related injuries

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101
Q

Which of the following is NOT a duty of a Primary Treating Physician (PTP)?

A

Managing the entire care process independently without reporting to any other entity

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102
Q

What is the significance of predesignating a physician in the workers’ compensation system?

A

The employee’s predesignated physician can treat the worker even if they are not part of the employer’s MPN or HCO

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103
Q

What is a Health Care Organization (HCO)?

A

A managed care organization certified by the DWC to provide health care to employees injured at work

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104
Q

In the context of the workers’ compensation system, which of the following is a violation of Labor Code § 139.3?

A

Referring a patient to a facility where the physician has a financial interest without disclosing it

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105
Q

What is required for a physician to use a Physician Assistant (PA) in treating an injured worker?

A

The physician must evaluate the PA’s ability and provide supervision, with a limit of supervising two PAs at a time

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106
Q

An employee who fails to predesignate a physician will be treated by:

A

The HCO or MPN selected by the employer

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107
Q

Which of the following statements is TRUE about Medical Provider Networks (MPNs)?

A

Employees in an MPN must follow the rules and guidelines set by the network

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108
Q

Which of the following best describes the role of a secondary treating physician?

A

They provide additional opinions or treatment but do not manage the case

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109
Q

What is the purpose of a Health Care Organization (HCO) in the workers’ compensation system?

A

To manage and deliver medical treatment to employees injured at work

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110
Q

Which of the following is a requirement for an injured worker to receive treatment from a predesignated physician?

A

The physician must have treated the employee in the past and have the employee’s medical records

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111
Q

Which of the following must be disclosed if a physician has a financial interest in a facility to which they are referring a patient?

A

The financial interest the physician has in the facility

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112
Q

What role does a Primary Treating Physician (PTP) play in determining an injured worker’s eligibility for vocational rehabilitation?

A

They determine medical eligibility for vocational rehabilitation services for injuries before January 1, 2004

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113
Q

In which of the following situations is a cross-referral considered legal?

A

When two doctors, without any financial interest, refer patients to each other based solely on patient care needs

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114
Q

Which statement is TRUE regarding the supervision of Physician Assistants (PAs) under California workers’ compensation law?

A

PAs must have all care they provide supervised and approved by a licensed physician

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115
Q

What must an employer provide when contracting with a Health Care Organization (HCO)?

A

A choice of at least one HCO and an open enrollment period for employees

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116
Q

If an employee is dissatisfied with the medical treatment provided by the MPN, what is their next step?

A

The employee must request a second opinion from another doctor within the MPN

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117
Q

What is the deadline for submitting the Doctor’s First Report of Occupational Injury or Illness (DFR) after the injured worker’s first visit?

A

5 working days

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118
Q

Which report is required to document the ongoing treatment and condition of an injured worker during active treatment?

A

Primary Treating Physician’s Progress Report (PR-2)

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119
Q

What must a treating physician include when requesting treatment through a Request for Authorization (RFA) form?

A

Documentation substantiating the need for the requested treatment

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120
Q

When should a Primary Treating Physician (PTP) submit a Permanent and Stationary Report (PR-3 or PR-4)?

A

When the employee’s condition becomes stable and unlikely to improve

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121
Q

If a physician fails to submit a Doctor’s First Report of Occupational Injury or Illness (DFR), what consequences might arise?

A

The injured worker’s benefits may be delayed, and the physician may face civil penalties

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122
Q

What information is NOT required in the Doctor’s First Report of Occupational Injury or Illness (DFR)?

A

The estimated cost of treatment

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123
Q

What triggers the need for a Primary Treating Physician’s Progress Report (PR-2)?

A

All of the above

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124
Q

Which form must be completed by a treating physician to request diagnostic tests or other medical services for an injured worker?

A

Request for Authorization (RFA)

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125
Q

Under what circumstances is a specialist required to complete a Doctor’s First Report of Occupational Injury or Illness (DFR)?

A

Only if the treating physician has not already submitted a DFR

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126
Q

What is the purpose of the Permanent and Stationary Report (PR-3 or PR-4)?

A

To document the injured worker’s condition once it becomes stable and unlikely to improve

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127
Q

How often must a Primary Treating Physician (PTP) submit progress reports during periods of active treatment?

A

At least every 45 days

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128
Q

Which of the following is required in the Permanent and Stationary Report (PR-3 or PR-4)?

A

A history of the injury and the patient’s complaints

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129
Q

If a treating physician makes a verbal request for treatment, what must they do next?

A

Confirm the request in writing using the Request for Authorization (RFA) form

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130
Q

Which form is used to assess the existence and extent of permanent impairment after an employee’s condition becomes permanent and stationary?

A

Permanent and Stationary Report (PR-3 or PR-4)

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131
Q

What should a PTP do if the injured worker’s condition requires new durable medical equipment or orthotic devices?

A

Report the need in a Primary Treating Physician’s Progress Report (PR-2)

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132
Q

What is the primary purpose of Evidence-Based Medicine (EBM)?

A

To integrate the best available research evidence with clinical expertise and patient values

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133
Q

Which schedule must be followed when evaluating and treating ill and injured workers in California?

A

Medical Treatment Utilization Schedule (MTUS)

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134
Q

Which concept is central to the treatment of work-related injuries according to the MTUS?

A

Functional improvement

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135
Q

The MTUS is presumed correct on the issue of medical treatment. How can this presumption be successfully challenged?

A

By providing high-quality scientific medical evidence

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136
Q

What is the role of the Medical Evidence Evaluation Advisory Committee (MEEAC)?

A

To provide recommendations on updates to the MTUS

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137
Q

Which of the following is NOT a clinical topic covered by the MTUS?

A

Cardiac conditions

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138
Q

What does the MTUS provide for medical providers?

A

Treatment frequency, intensity, and duration recommendations

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139
Q

What is the most recent role clarified in the MTUS revisions?

A

The role of the MTUS as the standard of medical care for work-related illness or injury

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140
Q

Which model is highlighted in the MTUS for understanding chronic pain?

A

Biopsychosocial

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141
Q

What is functional improvement as defined by the MTUS?

A

Clinically significant improvement in activities of daily living or reduction in work restrictions

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142
Q

The MTUS is periodically updated to include new evidence. Which guideline chapters are specifically mentioned as being incorporated?

A

ACOEM and ODG

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143
Q

According to the MTUS, which factor is a better predictor of chronic pain than clinical findings?

A

Psychosocial factors

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144
Q

What is the primary goal of Utilization Review (UR) in workers’ compensation?

A

To avoid unnecessary testing and treatments that may be harmful and costly

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145
Q

Who is required by law to have a Utilization Review (UR) program in place?

A

All employers or their workers’ compensation claims administrators

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146
Q

What must be filed with the DWC Administrative Director as part of the UR program?

A

UR plans

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147
Q

Who can approve a treatment request in the Utilization Review (UR) process?

A

Any member of a UR organization

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148
Q

In what situation must a treatment request be reviewed by a physician during the UR process?

A

When the request is not approved at the adjuster or claims representative level

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149
Q

What can a chiropractic physician reviewer evaluate during the UR process?

A

Tests or treatments within the scope of chiropractic practice

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150
Q

How soon must a decision be communicated to the treating doctor after a concurrent or prospective request?

A

Within 5 working days

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151
Q

What happens if additional information needed for a UR decision is not received within 14 days?

A

The request is denied

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152
Q

Which of the following describes “Prospective Review” in the UR process?

A

Review conducted prior to the delivery of medical services

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153
Q

What is the maximum timeframe for making a decision related to an expedited review in the UR process?

A

72 hours

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154
Q

What is the main purpose of Independent Medical Review (IMR) in California’s workers’ compensation system?

A

To resolve disputes about the medical treatment of injured employees

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155
Q

Who can request an Independent Medical Review (IMR)?

A

The injured employee or their designee

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156
Q

What must be submitted with the IMR application within 30 days to request a review?

A

Signed IMR application and a copy of the UR denial or modification

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157
Q

What could cause an IMR to be terminated?

A

The treatments in dispute are authorized

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158
Q

Who must make decisions on the medical necessity of treatment requests during IMR?

A

Licensed physicians knowledgeable in the treatment of the injured worker’s condition

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159
Q

What is the highest-ranking standard to be used when making medical necessity decisions during IMR?

A

The Medical Treatment Utilization Schedule (MTUS)

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160
Q

Within how many days must the final IMR decision be provided in writing to all parties?

A

14 days

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161
Q

On what grounds can an IMR decision be appealed?

A

The final determination was procured by fraud

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162
Q

What must be done if a UR decision also involves a dispute of liability?

A

The request for IMR is extended to 30 days after the liability dispute is resolved

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163
Q

What is required for an expedited IMR request?

A

The treating physician’s certification that the employee faces an imminent and serious threat to their health

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164
Q

What role do physicians play in disability evaluations?

A

Determining the impairment rating and eligibility for disability payments

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165
Q

Which of the following forms might a Primary Treating Physician (PTP) use to report a permanent disability?

A

DWC PR-3 or PR-4

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166
Q

What is the purpose of the Disability Evaluation Unit (DEU)?

A

To assign permanent disability ratings based on physicians’ evaluations

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167
Q

Which of the following is NOT a required component of a final disability evaluation report?

A

Workers’ compensation insurance policy number

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168
Q

What does the term “Permanent and Stationary” (P&S) indicate in a disability evaluation?

A

The worker’s condition has stabilized and is unlikely to improve further

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169
Q

What is the Almaraz-Guzman Standard used for?

A

Rebutting a permanent disability rating when the AMA Guides are deemed inadequate

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170
Q

According to the AMA Guides, what is the definition of “impairment”?

A

A loss, loss of use, or derangement of any body part, organ system, or organ function

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171
Q

How is “disability” defined according to the AMA Guides?

A

An alteration of an individual’s capacity to meet personal, social, or occupational demands due to impairment

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172
Q

What is the primary goal of the AMA Guides?

A

) To provide a standardized, objective approach to evaluating medical impairments

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173
Q

Which method is commonly used in the AMA Guides to assess spinal impairment?

A

Diagnosis-Related Estimate (DRE)

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174
Q

What is the purpose of the Combined Values Chart in the AMA Guides?

A

To combine multiple impairment ratings into a single whole person impairment (WPI)

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175
Q

In what scenario might a physician use the Range of Motion (ROM) method for assessing spinal impairment?

A

When the condition cannot be easily categorized, such as multilevel fusions

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176
Q

What is the maximum additional percentage a physician can add to a Whole Person Impairment (WPI) rating for pain, according to the AMA Guides?

A

3%,

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177
Q

What is a key difference in how the AMA Guides and the previous system in California evaluate permanent disability?

A

The AMA Guides focus on impairment related to activities of daily living, rather than work capacity

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178
Q

What must a physician provide when using an alternative rating method under the Almaraz-Guzman Standard?

A

Substantial medical evidence and a clear rationale for the chosen method

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179
Q

What is NOT a purpose of a disability evaluation in the workers’ compensation system?

A

To decide the worker’s guilt or innocence in causing the injury

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180
Q

What approach should a physician take when evaluating a worker using an assistive device, according to the AMA Guides?

A

Evaluate with and without the device when possible

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181
Q

What is the primary focus of a physician’s responsibility when conducting a permanent disability evaluation using the AMA Guides?

A

Providing an impairment rating

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182
Q

In California, what does the AMA Guides’ approach to pain in disability evaluations involve?

A

A conservative addition of up to 3% to the WPI rating when pain is greater than normally associated with the injury,

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183
Q

What is required of a physician when documenting the process used to derive an AMA Guides impairment rating?

A

Thorough documentation of the rationale and references to the relevant AMA Guides sections

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184
Q

What is the primary role of a Qualified Medical Evaluator (QME)?

A

To conduct medical-legal evaluations in workers’ compensation cases

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185
Q

Who appoints Qualified Medical Evaluators (QMEs) in California?

A

The Division of Workers’ Compensation Medical Unit

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186
Q

What is required for a physician to be eligible to become a QME?

A

They must devote at least one-third of their practice to providing direct medical treatment

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187
Q

When can an Agreed Medical Evaluator (AME) be used?

A

Only if both the employee and employer agree on a physician

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188
Q

What happens if the represented parties cannot agree on an AME?

A

Either party may request a QME panel to resolve the dispute

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189
Q

How long is the appointment term for a Qualified Medical Evaluator (QME)?

A

) Two years

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190
Q

Who can request a medical-legal evaluation if there is a disagreement with the treating physician’s evaluation?

A

Either the employer or the employee

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191
Q

What is the purpose of a medical-legal evaluation in a workers’ compensation case?

A

To determine medical issues relevant to the workers’ compensation claim

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192
Q

What must the QME do if there is no referral letter accompanying the request for an evaluation?

A

Determine the relevant issues based on available records and discussion with the injured worker

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193
Q

What is required if an unrepresented employee fails to request a QME panel within 10 days after the employer’s request?

A

the employer may then request a QME panel

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194
Q

How many QMEs are listed in a QME panel generated by the DWC Medical Unit?

A

Three

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195
Q

What must a QME report include to be considered complete?

A

The physician’s findings and the reasons for all opinions

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196
Q

How soon must the employer pay reasonable charges for a medical-legal report under the fee schedule?

A

Within 60 days

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197
Q

When can a Permanent and Stationary (P&S) report be contested in a workers’ compensation case?

A

When either party objects to the findings

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198
Q

What must be addressed in all medical-legal reports regarding permanent disability?

A

The issue of apportionment

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199
Q

What is the primary purpose of a medical-legal report in a workers’ compensation case?

A

To assist nonmedical personnel in making decisions affecting the worker’s life

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200
Q

Which of the following is a required element in a medical-legal report?

A

History of present injury or illness

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201
Q

Why is it important for a medical-legal report to be clear, concise, and internally consistent?

A

To enable nonmedical personnel to make informed decisions

202
Q

What must be included in the “Identifying Information” section of a medical-legal report?

A

Date of the report, name of the applicant, and date of injury

203
Q

How much face-to-face time is required for a psychiatric evaluation in a medical-legal report?

A

60 minutes

204
Q

In the context of workers’ compensation, what does “apportionment of disability” refer to?

A

The degree to which permanent disability is due to pre-existing conditions

205
Q

Which form must be reviewed and possibly commented on by the physician for unrepresented workers in a QME evaluation?

A

DEU Form 100

206
Q

What is the significance of using appropriate terminology in a medical-legal report?

A

To align with the logic and definitions of workers’ compensation law

207
Q

What should be included in the “Present Complaints” section of a medical-legal report?

A

Detailed description of the patient’s current complaints and related activities

208
Q

What should a physician do if there are conflicting accounts of how the injury occurred?

A

Provide an opinion conditionally based on each possible scenario

209
Q

Why is it important to summarize important medical events or conditions in the report?

A

) To provide context for the injury and its impact on the worker’s disability

210
Q

What is the role of a physician in determining the cause of injury in a medical-legal report?

A

To explain how the injury is related to the worker’s employment

211
Q

What is the primary purpose of Labor Code § 4600 in relation to medical treatment for injured workers?

A

To guarantee treatment that cures or relieves the effects of the injury

212
Q

Which type of medical treatment dispute must be resolved through Independent Medical Review (IMR)?

A

Current medical treatment disputes

213
Q

Which of the following must a medical-legal report NOT include when discussing future medical treatment?

A

Exact dollar amounts for future treatment

214
Q

Why is it important for a physician to provide detailed reasoning for each opinion in a medical-legal report?

A

To prevent the report from being deemed worthless in the workers’ compensation system

215
Q

What role does the WCAB play in the evaluation of future medical treatment needs?

A

They assess the reports from the treating physician and possibly a QME at the time care is requested

216
Q

What must be disclosed in the medical-legal report regarding other individuals involved in the evaluation process?

A

Their names, qualifications, and roles in the evaluation

217
Q

When is a physician required to provide future medical treatment in a workers’ compensation case?

A

When it is needed to relieve or cure the effects of the injury

218
Q

What happens if a medical-legal report is submitted without adequate reasoning behind the medical opinions?

A

The report is considered worthless in the workers’ compensation system

219
Q

In what situation would the WCAB not be bound by a physician’s estimate of future medical needs?

A

When reviewing a P&S report

220
Q

Which of the following must be included in every medical-legal report under penalty of perjury?

A

A mandatory declaration stating that the report is true and correct

221
Q

Why should a physician avoid providing finite numbers and dollar amounts for future medical treatment in their reports?

A

Because the future needs cannot be precisely predicted

222
Q

What must a physician disclose if they have a significant beneficial interest in a facility used in the evaluation?

A

Their proprietary interest or co-ownership of the facility

223
Q

What is the purpose of the Official Medical Fee Schedule (OMFS)?

A

To establish the maximum allowable fee for services

224
Q

Which fee schedule is the Physician Fee Schedule based on?

A

Resource-Based Relative Value Scale (RBRVS)

225
Q

What is a key element of the RBRVS fee schedule?

A

Relative value units (RVUs)

226
Q

How often is the Physician Fee Schedule updated?

A

Annually

227
Q

What is required for a medical provider to request an Independent Bill Review (IBR)?

A

Completion of a second bill review

228
Q

Which billing form is used by health-care providers for paper submissions?

A

Form CMS-1500

229
Q

What is the time limit for submitting a Request for Second Bill Review after receiving an Explanation of Review (EOR)?

A

90 days

230
Q

What factor is used to adjust payments for geographic differences in costs under the RBRVS system?

A

Geographic Adjustment Factor (GAF)

231
Q

What does the Multiple Procedure Payment Reduction (MPPR) apply to?

A

Physical medicine and surgery

232
Q

What is the primary benefit of electronic billing over paper billing?

A

Faster payment processing

233
Q

Which entity currently serves as the Independent Bill Review Organization (IBRO) for California workers’ compensation?

A

Maximus Federal Services

234
Q

What is the basis for calculating maximum fees for anesthesia services under the Physician Fee Schedule?

A

A separate conversion factor for anesthesia, A single national conversion factor

235
Q

What must be included with a Request for Second Bill Review?

A

Additional documentation supporting the billing

236
Q

How are missed appointments communicated under California Specific Codes?

A

WC012

237
Q

What is required for a provider to appeal an IBR determination?

A

Filing with the Workers’ Compensation Appeals Board (WCA

238
Q

Which regulation outlines the formulas for calculating fees for services other than anesthesia?

A

8 CCR §9789.12.2

239
Q

What is the deadline for claims administrators to pay an electronic bill after receiving it?

A

15 days

240
Q

Which billing format is consistent with HIPAA standards in California workers’ compensation?

A

Electronic Billing

241
Q

What happens if an IBR application is withdrawn after assignment to an IBRO?

A

The fee will not be reimbursed

242
Q

What is one of the ground rules that differ from Medicare under the Physician Fee Schedule?

A

Multiple Procedure Payment Reduction (MPPR) for Radiology Diagnostic Imaging

243
Q

What is the main responsibility of the DWC Audit and Enforcement Unit?

A

To conduct audits of claims administrators to ensure compliance with workers’ compensation laws

244
Q

How often are claims administrators normally subject to routine investigations?

A

Once every five years

245
Q

What triggers a targeted investigation of a claims administrator by the DWC?

A

A credible complaint or failure of a routine investigation

246
Q

What happens if a URO fails a routine investigation?

A

The DWC may return for a targeted investigation

247
Q

What must MPNs and HCOs demonstrate to maintain approval or certification?

A

Compliance with regulations regarding employee notifications and provider lists

248
Q

Who can file complaints about the behavior of Qualified Medical Evaluators?

A

Injured workers, attorneys, and claims administrators

249
Q

What disciplinary actions can the DWC take against a QME for violations?

A

Formal reprimand, suspension, or revocation of QME status

250
Q

Under what circumstances can a QME be suspended without a hearing?

A

If their medical license has been revoked

251
Q

What is the role of the DWC Medical Unit in overseeing UROs?

A

Investigating compliance with UR regulations and assessing penalties

252
Q

Which of the following is NOT a potential ground for QME disciplinary action?

A

Failure to pay administrative fees on time

253
Q

What is the main purpose of the DWC’s investigation of UROs?

A

To ensure that responses to physicians’ requests for treatment are timely and comply with regulations

254
Q

Who is responsible for overseeing employers’ compliance with regulations related to workers’ compensation insurance?

A

The Division of Labor Standards and Enforcement and the Department of Insurance

255
Q

What is the primary responsibility of a treating physician in the workers’ compensation system?

A

To treat the patient fairly and ethically

256
Q

What role does the Labor Code play in regulating medical-legal evaluations?

A

It clarifies and codifies the role of evaluating physicians

257
Q

Why might the appearance of impropriety develop in workers’ compensation cases?

A

Physicians may have business relationships with parties involved

258
Q

What is a QME required to do when conducting a medical-legal evaluation?

A

Personally examine the applicant and take a thorough history

259
Q

According to the chapter, what should a physician do if a worker refuses to provide information or sign a release?

A

Litigate the issue before the WCAB

260
Q

Which of the following is true about the use of interpreters during medical-legal evaluations?

A

The employer or insurance company must provide a certified interpreter

261
Q

What is one key difference between a treating physician’s report and a QME’s report?

A

A treating physician’s report is not generated from a disputed issue

262
Q

What is a physician advised to do if an injured worker appears nervous or evasive during an exam?

A

Understand the worker’s possible apprehension and try to be objective

263
Q

What should a QME mention in their report if a certified interpreter was used?

A

The interpreter’s name

264
Q

In what scenario might a QME exam be recorded?

A

If both parties agree and the QME consents to the recording

265
Q

What is the maximum time an injured worker can be kept waiting before they can terminate the QME exam?

A

1 hour

266
Q

Under which condition can a QME terminate an exam?

A

If the injured worker is intoxicated

267
Q

If an injured worker terminates an exam due to discriminatory conduct, what is the next step?

A

The worker may request a new QME

268
Q

What happens if a judge determines there was no good cause for terminating the QME exam?

A

The cost of the evaluation is deducted from the worker’s award

269
Q

Can a QME become a treating physician after conducting an evaluation?

A

Yes, but only if the injured worker requests it

270
Q

Under what condition may a QME provide treatment to an injured worker after the evaluation?

A

If the injured worker formally requests the QME as their treating physician

271
Q

What must a QME do if they disagree with the treating physician’s assessment that the worker’s condition is permanent and stationary?

A

Discuss the basis for their disagreement in the report

272
Q

In what scenario is ex parte communication allowed for a QME?

A

When requesting medical records in writing with a copy served on the injured worker

273
Q

What is considered ex parte communication by a QME?

A

Contacting the defense attorney for additional records without informing the injured worker

274
Q

How should a QME handle receiving nonmedical records or films?

A

They should only view them if neither party objects

275
Q

Who has the initial discretion to terminate a QME exam due to violations of ethical guidelines?

A

The injured worker

276
Q

What must a QME do after rescheduling an appointment due to a delay?

A

Inform the claims administrator of the new appointment time within five days

277
Q

When can an injured worker terminate a QME exam due to improper conduct?

A

If the evaluator makes improper sexual advances

278
Q

What must happen if a new QME examination is necessary after a QME becomes the treating physician?

A

A new QME panel must be requested

279
Q

What is a QME prohibited from doing regarding nonmedical records if a party objects?

A

Viewing the nonmedical records or films

280
Q

What is required on bills submitted by treating physicians for injured workers?

A

A declaration that they were not in violation of Labor Code § 139.3 (self-referral)

281
Q

Which types of self-referrals are specifically prohibited?

A

Referrals to facilities where the physician or their family has a financial interest

282
Q

What must a physician do if they refer a patient to a facility in which they have a financial interest?

A

Disclose their financial interest to the patient

283
Q

In what case is a physician not required to obtain preauthorization for physical therapy referrals?

A

When the physician’s regular practice is outside a metropolitan area with no alternatives available within 25 miles

284
Q

What is the consequence of violating referral prohibitions under Labor Code § 139.31(e)?

A

A misdemeanor charge

285
Q

Under what circumstances may medical records related to HIV status be disclosed without patient authorization?

A

When the patient claims HIV infection through an employment-related exposure

286
Q

What should a physician do if they receive a subpoena for medical records related to a work injury?

A

Respond to the subpoena, but consult with the patient or their attorney first

287
Q

Which of the following actions is considered a felony under Labor Code § 3219?

A

Offering compensation to a claims adjuster for referrals

288
Q

What is required for a valid subpoena related to a workers’ compensation claim?

A

The injured worker must receive a copy of the subpoena

289
Q

What should treating physicians explain to patients about confidentiality in workers’ compensation cases?

A

How their medical information will be shared with employers and insurers

290
Q

What are QMEs and AMEs required to ensure in their evaluations?

A

Maximum compensation for the injured worker

291
Q

Which of the following is considered appropriate advertising for QMEs?

A

Listing the physician’s area of practice and languages spoken

292
Q

What is the penalty for making false or fraudulent workers’ compensation claims?

A

Up to five years in prison or a fine of up to $50,000

293
Q

What must evaluators avoid when providing medical opinions?

A

Accepting compensation contingent on writing a biased report

294
Q

Which of the following actions is NOT a violation of the self-referral laws?

A

Referring a patient for a nonprohibited service with proper disclosure

295
Q

What should be used to bill for treatment and most reports under California workers’ compensation laws?

A

Official Medical Fee Schedule

296
Q

When should the QME Appointment Notification Form be completed and sent to the involved parties?

A

Within 10 working days of scheduling

297
Q

If an injured worker makes a QME appointment, what is the maximum number of days allowed before the appointment to avoid difficulties in obtaining records?

A

25 days

298
Q

What form must be submitted with the QME evaluation for disability rating by the DEU?

A

DEU Forms 100 and 101

299
Q

What must be included in the total package sent to the DEU office for rating a QME evaluation?

A

QME evaluation, Findings Summary Form, DEU Forms 100 and 101, and Proof of Service

300
Q

What is the time frame for serving a QME report for injuries occurring after January 1, 1994?

A

30 days

301
Q

How long does a QME have to request an extension for a report if test results are delayed?

A

25 days

302
Q

Which form must be used to request a time extension for submitting a QME report?

A

QME Form 112

303
Q

What should be done if the medical records are not received by the QME appointment date?

A

Contact the employer/insurer to request records

304
Q

Who is responsible for serving the QME report to the DWC or WCAB?

A

The parties involved

305
Q

What is the fee for requesting Independent Bill Review (IBR)?

A

$250.00

306
Q

What happens if a QME report is not completed within the extended time frame?

A

The original evaluation may be deemed inadmissible

307
Q

Which form is used to notify the parties about the QME appointment?

A

QME Form 110

308
Q

Who must receive a copy of the QME report in a panel QME case for an unrepresented injured worker?

A

The injured worker, claims administrator, and local DEU office

309
Q

What is required to consolidate separate IBR requests?

A

Common issues of law and fact or similar services

310
Q

What form should be used if an Independent Bill Review request is withdrawn?

A

No specific form required

311
Q

What is the maximum amount of a dispute that can be consolidated in IBR?

A

$4,000,

312
Q

How should the QME report be served to all parties?

A

With proof of service attached

313
Q

If a provider wishes to appeal an IBR determination, how long do they have to file a petition with the WCAB?

A

20 days

314
Q

What should be done if the injured worker does not have the required DEU Forms 100 and 101?

A

Have the worker complete Form 100 at the appointment and ensure Form 101 is received

315
Q

What does “AA or A/A” stand for in workers’ compensation terminology?

A

Applicant’s attorney

316
Q

What is an “Accepted claim” in workers’ compensation?

A

A claim in which the insurance company agrees that an employee’s injury or illness is covered by workers’ compensation

317
Q

What does “ACOEM” stand for?

A

American College of Occupational and Environmental Medicine

318
Q

Who is the “AD” in the context of workers’ compensation?

A

Administrative Director of the Division of Workers’ Compensation

319
Q

Which of the following best defines “ADA”?

A

Americans with Disabilities

320
Q

What does “ADL” stand for in the workers’ compensation field?

A

Activities of Daily Living

321
Q

Which of the following is the role of an “Administrative Law Judge (WCALJ, ALJ, Judge)”?

A

To preside over disputes in workers’ compensation cases

322
Q

What is an “Aggravation” in the context of workers’ compensation?

A

A worsening of a non-industrial pre-existing condition due to work exposure

323
Q

Who is an “Agreed medical evaluator (AME)”?

A

The doctor agreed upon by the worker’s attorney and the insurance company

324
Q

What is an “Agreed QME”?

A

An evaluator chosen when an objection is made to an issued panel and both parties agree on the QME

325
Q

What is meant by “Alternative work” in the workers’ compensation system?

A

A new job offered by the former employer that meets the employee’s work restrictions

326
Q

What is the “American Medical Association (AMA)” known for in workers’ compensation?

A

Publishing the “Guides to the Evaluation of Permanent Impairment”

327
Q

What does “AOE” stand for in the context of a workers’ compensation claim?

A

Arising Out of Employment

328
Q

What is the role of the “Appeals board” in workers’ compensation?

A

To review and reconsider decisions of workers’ compensation administrative law judges

329
Q

Who is typically the “Applicant” in a workers’ compensation case?

A

The injured employee who files a claim

330
Q

Who does an “Applicants’ attorney” represent in a workers’ compensation case?

A

The injured employee

331
Q

What is an “Application for adjudication of claim”?

A

A form filed to open a case at the Workers’ Compensation Appeals Board office

332
Q

What does “Apportionment” determine in a workers’ compensation case?

A

How much of an employee’s permanent disability is due to the work injury versus other causes

333
Q

What does “AOE/COE” mean in workers’ compensation?

A

Arising Out of and Occurring in the Course of Employment

334
Q

What is the role of the “Audit Unit” in the Division of Workers’ Compensation?

A

Ensuring that insurance companies, self-insured employers, and third-party administrators adhere to the regulations and laws governing workers’ compensation claims.

335
Q

What does an “Award” refer to in the workers’ compensation system?

A

A decision by the Workers’ Compensation Appeals Board regarding benefits

336
Q

What does “AWW or AWE” stand for in workers’ compensation?

A

Average Weekly Wage or Earnings

337
Q

Fair Employment and Housing Act (FEHA) prohibits discrimination against:

A

People with disabilities

338
Q

The Family and Medical Leave Act (FMLA) provides up to how many weeks of unpaid, job-protected leave per year?

A

12 weeks

339
Q

Filing refers to:

A

Sending or delivering a document to an employer or a government agency

340
Q

A Final Order is:

A

An order, decision, or award made by a workers’ compensation judge that has not been appealed

341
Q

Findings & Award (F&A) is:

A

A written decision by a workers’ compensation administrative law judge about an employee’s case

342
Q

First Aid in the workers’ compensation system refers to:

A

Treatment provided by a physician or licensed medical provider on a one-time basis for a minor condition

343
Q

A Flare-up of a Pre-Existing Condition is also known as:

A

Recurrence of a Pre-Existing Condition

344
Q

Fraud in the workers’ compensation system involves:

A

Knowingly making a false statement to obtain or deny workers’ compensation benefits

345
Q

Functional Capacity Evaluation (FCE) is:

A

A formal assessment of an individual’s physical capabilities

346
Q

Future Earning Capacity (FEC) refers to:

A

A multiplier that increases the disability rating based on wage loss caused by an injury

347
Q

Future Medical Treatment is:

A

Treatment anticipated at some time in the future to cure or relieve the effects of an injury

348
Q

Ghostwriting in medical-legal reports is:

A

When a medical report is prepared by someone other than the physician who performed the evaluation

349
Q

A Health Care Organization (HCO) is:

A

An organization certified by the DIR to provide managed medical care within the workers’ compensation system

350
Q

Hearings in the workers’ compensation system are:

A

Legal proceedings where a judge discusses issues in a case or receives information

351
Q

Impairment is defined as:

A

The reduction or loss of function of an organ or body part

352
Q

An Impairment Rating is:

A

A percentage estimate of how much normal use of the worker’s injured body parts has been lost

353
Q

In Pro Per refers to:

A

An injured worker not represented by an attorney and acting as their own attorney

354
Q

An Independent Contractor is someone who:

A

Has control over how their work is done and is not considered an employee

355
Q

An Independent Medical Examiner (IME) is:

A

The same as a Qualified Medical Examiner (QME)

356
Q

The Industrial Medical Council (IMC):

A

No longer exists and is now called the Medical Unit

357
Q

Independent Medical Review (IMR) allows an employee to:

A

Seek a second and third opinion if they dispute their physician’s recommended tests or treatments

358
Q

An Information & Assistance (I&A) Officer:

A

Answers questions and assists injured workers within the DWC

359
Q

The Information & Assistance Unit (I&A):

A

Provides information and informally resolves disputes in workers’ compensation claims

360
Q

An Injured Worker is:

A

Another term for an injured employee or applicant

361
Q

Injury in the workers’ compensation system refers to:

A

A new injury, illness, or a pre-existing condition made worse by work-related exposure

362
Q

The Injury and Illness Prevention Program (IIPP):

A

Is a required health and safety program that employers must implement

363
Q

A Judge (WCALJ, WCJ) in the workers’ compensation system is:

A

Also known as a Workers’ Compensation Administrative Law Judge

364
Q

A Lien in the workers’ compensation context is:

A

A right or claim for payment against a workers’ compensation case

365
Q

Maximum Medical Improvement (MMI) is:

A

When the injured worker’s condition is well stabilized and unlikely to change substantially

366
Q

A Mediation Conference is:

A

A voluntary conference held to resolve a dispute if an employee is not represented by an attorney

367
Q

Medical Care in the workers’ compensation system is also known as:

A

Medical Treatment

368
Q

A Medical Determination is:

A

A decision made by the primary treating physician regarding the employee’s eligibility for compensation

369
Q

A Medical-Legal Report is:

A

A report written by a doctor to clarify disputed medical issues

370
Q

A Medical Provider Network (MPN) is:

A

An entity or group of health-care providers set up to treat workers injured on the job

371
Q

Medical Treatment is defined as:

A

Treatment reasonably required to cure or relieve the effects of a work-related injury or illness

372
Q

The Medical Treatment Utilization Schedule (MTUS):

A

Contains guidelines on effective treatments for work-related injuries

373
Q

The Medical Unit within the DWC:

A

Oversees MPNs, IMR physicians, HCOs, QMEs, and other medical-related entities

374
Q

Modified Work is:

A

An injured worker’s old job with some changes to accommodate their abilities

375
Q

Objective factors refer to:

A

Measurements, direct observations, and test results contributing to permanent disability

376
Q

Occupational disease is:

A

A disease caused in whole or in part by work

377
Q

Off calendar (OTOC) means:

A

A WCAB case in which there is no pending action

378
Q

Offer of modified or alternative work (DWC form #AD 10133.53) is:

A

A form sent to an injured worker offering modified or alternative work instead of a supplemental job displacement benefit

379
Q

Offer of modified or alternative work form (RU-94) applies to:

A

Injured workers who were injured before 2004 and may not return to their old job

380
Q

Official Medical Fee Schedule (OMFS) refers to:

A

A fee schedule used for payment of medical services required to treat work-related injuries

381
Q

Order Approving Compromise and Release (OACR) is:

A

An order issued by a workers’ compensation judge that finalizes a settlement agreement

382
Q

OSHA stands for:

A

Occupational Health and Safety Act, Office of Safety and Health Appeals

383
Q

P&S report is:

A

A medical report written by a treating physician when the employee’s condition has stabilized

384
Q

Panel-qualified medical evaluator (QME/PQME) refers to:

A

A list of three independent QMEs from which the injured worker selects one for evaluation

385
Q

Party in a workers’ compensation case usually includes:

A

The insurance company, employer, attorneys, and any other person with an interest in the claim

386
Q

Penalty in a workers’ compensation case refers to:

A

An amount paid by the employer or insurance company for not handling a claim correctly

387
Q

Permanent and stationary status (P&S) means:

A

The point at which the employee has reached maximum medical improvement

388
Q

Permanent disability (PD) is defined as:

A

Any lasting disability that results in a reduced earning capacity after maximum medical improvement is reached

389
Q

Permanent disability advance (PDA) is:

A

A voluntary lump sum payment of permanent disability the injured worker is due in the future

390
Q

Permanent disability rating (PDR) refers to:

A

A percentage that estimates how much a job injury permanently limits the kinds of work an individual can do

391
Q

Permanent disability rating schedule (PDRS) is:

A

A DWC publication containing detailed information used to rate permanent disabilities

392
Q

Permanent disability payments are:

A

Mandatory biweekly payments based on the undisputed portion of permanent disability received before or after an award is issued

393
Q

Permanent partial disability (PPD) is:

A

A disability that interferes with the injured employee’s future earning capacity

394
Q

Permanent partial disability award is:

A

A final award of permanent partial disability made by a workers’ compensation judge or the WCAB

395
Q

Permanent partial disability (PPD) benefits are:

A

Payments the employee receives when their work injury partially limits the kinds of work they can do or their ability to earn a living

396
Q

Permanent total disability (PTD) refers to:

A

Disability considered to render an injured employee totally unable to have future earning capacity

397
Q

Permanent total disability (PTD) benefits are:

A

Payments the injured worker receives when they are considered permanently unable to earn a living

398
Q

Personal physician is:

A

A doctor licensed in California with an MD or DO degree who has treated an employee in the past and has their medical records

399
Q

Petition for reconsideration (Recon) is:

A

A legal process to appeal a decision issued by a workers’ compensation judge

400
Q

Physician in workers’ compensation refers to:

A

A medical doctor, osteopath, psychologist, acupuncturist, optometrist, dentist, podiatrist, or chiropractor licensed in California

401
Q

Predesignated physician is:

A

A physician who can treat an employee’s work injury if the employee advised the employer in writing prior to the injury and certain conditions are met

402
Q

Predesignation is:

A

The process employees use to tell an employer that they want their personal physician to treat them for a work injury

403
Q

Preponderance of evidence means:

A

Evidence that, when weighed against opposing evidence, is more convincing and a higher probability of truth

404
Q

Presumptive work-related injuries are:

A

Injuries or conditions defined by the legislature as presumptively work-related for workers in specific categories of employment, like peace officers or firefighters

405
Q

Primary treating physician (PTP) is:

A

The doctor with overall responsibility for treatment of an employee’s work injury or illness

406
Q

Proof of service is:

A

A form used to show that documents have been sent to specific parties

407
Q

Qualified injured worker (QIW) refers to:

A

A worker entitled to vocational rehabilitation benefits

408
Q

Qualified medical evaluator (QME) is:

A

An independent physician certified by the DWC Medical Unit to perform medical evaluations

409
Q

Qualified rehabilitation representative (QRR) is:

A

A person trained and able to evaluate, counsel, and place disabled workers in new jobs

410
Q

Reasonable medical probability means:

A

The standard a physician is expected to follow when rendering a medical opinion, meaning there is at least a 51% likelihood of certainty attached to the opinion

411
Q

Recurrence of a pre-existing condition refers to:

A

A previous industrial injury or illness that becomes symptomatic but not due to the effects of current employment

412
Q

Regular work means:

A

An employee’s old job, paying the same wages and benefits as paid at the time of an injury and located within a reasonable commuting distance of where the employee lived at the time of the injury

413
Q

Rehabilitation consultant is:

A

A DWC employee who oversees vocational rehabilitation procedures and helps resolve disputes

414
Q

Released from care means:

A

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

415
Q

Represented employee is:

A

An injured employee who is represented by an attorney

416
Q

Restrictions in workers’ compensation refer to:

A

A doctor’s description of the work the employee can and cannot do, Limitations on the benefits an employee can receive

417
Q

Salary continuation refers to:

A

A benefit that allows an injured worker to continue to receive their full salary in lieu of temporary disability benefits

418
Q

Self-administered claim is:

A

A workers’ compensation claim that is handled directly by the employer or a third-party administrator, not an insurance company

419
Q

Settlement in a workers’ compensation case refers to:

A

An agreement between the injured worker and the employer or insurance company that resolves the case

420
Q

Social Security disability benefits (SSDI) are:

A

Payments made by the Social Security Administration to cover total disability lasting at least a year or expected to result in death

421
Q

Specific injury is defined as:

A

An injury caused by one event at work, such as a fall

422
Q

State average weekly wage (SAWW) is:

A

The average weekly wage paid in the state of California to employees covered by unemployment insurance

423
Q

Statute of limitations refers to:

A

A law that puts time limits on how long a person has to file a legal claim

424
Q

Stipulated Findings and Award is:

A

An agreement between the injured worker and claims administrator that resolves the case

425
Q

Stipulation with Request for Award refers to:

A

An agreement on specific issues submitted to a judge for a decision on the remaining issues or approval

426
Q

Subjective factors in workers’ compensation are:

A

The amount of pain and other symptoms described by the injured worker, contributing to permanent disability

427
Q

Subsequent Injuries Benefits Trust Fund (SIBTF) is:

A

A state fund that pays additional benefits to workers who already had a disability or impairment at the time of injury

428
Q

Supplemental job displacement benefit (SJDB) is:

A

A $6,000 voucher for injured workers injured after 1/1/04 who are eligible for retraining or skill enhancement, offered if the employer does not offer regular, modified, or alternative work

429
Q

Temporary partial disability (TPD) refers to:

A

Payments made when the employee cannot do their usual job while recovering but can work with reduced hours or wages

430
Q

Temporary partial disability (TPD) benefits are:

A

Payments the employee receives if they can do some work while recovering, but earn less than before the injury

431
Q

Temporary total disability (TTD) is:

A

Payments made if the employee cannot work at all while recovering from an injury

432
Q

Temporary total disability (TTD) benefits are:

A

Payments the employee receives if they cannot work at all while recovering

433
Q

Treating doctor is:

A

The doctor with overall responsibility for treating the injured worker’s condition

434
Q

Uninsured Employers Fund (UEF) is:

A

A fund run by the DWC that pays benefits to injured workers whose employers are illegally uninsured

435
Q

Utilization review (UR) refers to:

A

The process used by insurance companies to decide whether to authorize and pay for treatment recommended by the treating physician or another doctor

436
Q

Vocational rehabilitation (VR) is:

A

A benefit for workers injured before 1/1/04 that helps pay for retraining or skill enhancement if the injured worker is unable to return to their job

437
Q

Workers’ Compensation Appeals Board (WCAB) is:

A

The court that handles workers’ compensation appeals

438
Q

Workers’ Compensation Insurance Rating Bureau (WCIRB) is:

A

An organization that provides information about workers’ compensation rates and statistics

439
Q

What are work restrictions?

A

A doctor’s description of the work an employee can and cannot do

440
Q

What does the term ‘Q.M.E’ stand for?

A

Qualified Medical Evaluator

441
Q

How is the term ‘A.M.E’ defined?

A

Agreed Medical Evaluator.

442
Q

Under Title 8, Section 35 of the California Code of Regulations, who within the DWC is tasked with appointing physicians as Qualified Medical Evaluators (QMEs)?

A

The Administrative Director of the D.W.C.

443
Q

What is the duration of a QME’s term?

A

2 years.

444
Q

What types of practitioners are encompassed by the term ‘physician’ according to the DWC?

A

California licensed: MDs, DOs, psychologists, acupuncturists, optometrists, dentists, podiatrists, and chiropractors.

445
Q

Who is eligible to become a QME?

A

Only Physicians, as defined by the Labor Code, can be a QME. Per the DWC, Physicians are: M.D.’s, D.O.’s,Psychologists, Acupuncturists, Dentists, Podiatrists, Chiropractors, and Optometrist.

446
Q

What are the four eligibility criteria required to become a QME?

A

Pass the QME competency examination.Complete a 12-hour writing course.Submit a form regarding Disclosure of Specified Financial Interests.Devote at least one-third of total practice time to providing direct medicaltreatment.

447
Q

True or false: QMEs are obligated to disclose all financial interests of 5% or more in any medical operation providing treatment, evaluations, goods, or services used within California’s Workers’ Compensation system.

A

True.

448
Q

What two alternative qualifications must a physician meet to become a QME if they lack the required amount of direct medical treatment experience?

A

The physician must have served as an AME (Agreed Medical Evaluator) on eight or more occasions in the 12 months prior to the end of their 2-year term.The physician must demonstrate that they are disabled, retired, or teaching.

449
Q

What is the minimum amount of time a QME must dedicate to direct medical treatment, and what are the two exceptions to this rule?

A

The QME served as an AME 8 or more times in the past year.The QME is disabled, retired, or is a teaching physician.

450
Q

What are the three distinct ways a physician can list a specialty?

A

Board certification in that specialty.Completed postgraduate specialty training (certificate of completion).Grandfathered in: held an appointment as a QME in that specialty on June 30, 2000.

451
Q

After satisfying the initial three qualifications to become a QME, what additional four criteria must be met after two years for reappointment?

A

Compliance with all applicable regulations and evaluation guidelines.Completion of at least 12 hours of continuing education.No more than 5 rejected reports by a Workers’ Compensation Judge.No termination, suspension, or probation by any licensing board..

452
Q

What are the two ways a QME can face termination or suspension?

A

The QME’s license to practice has been suspended, revoked, or terminated bytheir licensing board.The QME failed to pay the required fee for reappointment.

453
Q

How many locations can a QME register for QME work?

A

10

454
Q

Can a QME provide medical treatment to an injured worker?

A

Ordinarily, no. There are two exceptions: 1. The injured worker requests it. (For instance, a QME sees an injured worker. The injured worker then freely chooses the QME as their primary treating provider (PTP). The QME must then excuse themselves from future QME evaluations with that injured worker).2. Under emergency situations.

455
Q

Can a QME invite an injured worker to become a patient in their private practice while conducting an evaluation?

A

No.

456
Q

What are the two circumstances under which a QME is allowed to provide medical treatment to an injured worker?

A

The injured worker requests it. (For instance, a QME sees an injured worker. The injured worker then freely chooses the QME as their primary treating provider (PTP). The QME must then excuse themselves from future QME evaluations with that injured worker).Under emergency situations.

457
Q

How is the term ‘M.T.U.S.’ defined?

A

Medical Treatment Utilization Schedule

458
Q

What is the definition of the Medical Treatment Utilization Schedule (MTUS)?

A

The treatments adopted by the DWC’s Administrative Director.

459
Q

When a QME is required to deliver emergency treatment, should they follow the Medical Treatment Utilization Schedule (MTUS) or the guidelines of the American College of Occupational and Environmental Medicine (ACOEM)?

A

No. The QME can administer any necessary emergency treatment.

460
Q

What is the primary purpose of a medical-legal report generated by a QME?

A

To prove or disprove an aspect of a contested claim. Disputes can be about compensability, permanent or temporary disability, apportionment, permanent and stationary status, etc.

461
Q

Who relies on a QME’s medical-legal report?

A

Insurance companies, insurance adjusters, attorneys, worker’s compensation judges, other QMEs, other AMEs, and clinicians treating the injured worker.

462
Q

What is the primary responsibility of a QME?

A

To resolve disputes without bias towards either party (the defense attorney/ insurance company or the applicant’s attorney/ injured worker).

463
Q

Is a QME acknowledged as an expert or expert witness?

A

Yes. The QME’s opinions in the medical-legal report are used as “expert testimony” during depositions, employment lawsuits, third party lawsuits, disability determinations, and treatment determinations.

464
Q

In what contexts can a QME deliver medical-legal testimony?

A

The QME will serve as an expert witness and provide medical-legal testimony at a deposition or a WCAB hearing (Workers’ Compensation Appeals Board).

465
Q

What specific information must a QME include in their report for it to be admissible as evidence in a dispute under Labor Code section 5703?

A

Somewhere in the report, the QME must state, “There has not been a violation of Section 139.3 and that the contents of this report are true and correct to the best of my knowledge. This statement is made under penalty of perjury.”

466
Q

Can a QME request or accept any form of compensation for medical-legal expenses, such as rebates, refunds, or discounts, if the amount surpasses the fees permitted under Labor Code section 5307?

A

No. Labor Code section 5307 bars the QME from receiving compensation from a party or any source that is in addition to payment for the report.

467
Q

Is it legal for a QME to refer an injured worker for clinical lab services or related medical services if the physician or their immediate family holds a financial interest in the entity providing the service?

A

No. This is known as “self-referral” and this is illegal. This is grounds for disciplinary action.

468
Q

Who has the authority to issue medical-legal reports within the California workers’ compensation system?

A

QMEs, AMEs, and Primary Treating Physicians.

469
Q

If a QME misses the reappointment deadline for two years and fails to pay the fee, what actions must they take before re-registering?

A

The QME must take and pass the QME Competency Examination.

470
Q

What are five potential reasons that could lead to disciplinary action against a QME?

A

Self-referral (the QME tells injured workers to get treatment through the QME’s private medical practice).Ex Parte communications.Lack of availability for evaluation appointments within a reasonable time period (60 days).Submitting late reports.Prepares reports that are not up to standard.

471
Q

How is the Medical Treatment Utilization Schedule (MTUS) described or defined?

A

The treatments adopted by the DWC’s Administrative Director.

472
Q

When delivering emergency treatment, should a QME follow the Medical Treatment Utilization Schedule (MTUS) or the guidelines from the American College of Occupational and Environmental Medicine (ACOEM)?

A

No. The QME can administer any necessary emergency treatment.

473
Q

Who relies on the conclusions presented in a QME’s medical-legal report?

A

Insurance companies, insurance adjusters, attorneys, worker’s compensationjudges, other QMEs, other AMEs, and clinicians treating the injured worker.

474
Q

What is the primary role or duty of a QME?

A

To resolve disputes without bias towards either party (the defense attorney/instance company or the applicant’s attorney/ injured worker).

475
Q

In what types of settings is a QME permitted to provide medical-legal testimony?

A

The QME will serve as an expert witness and provide medical-legal testimony at a deposition or a WCAB hearing (Workers’ Compensation Appeals Board).

476
Q

Within the California workers’ compensation system, who is granted the authority to issue a medical-legal report?

A

QMEs, AMEs, and Primary Treating Physicians.

477
Q

If a QME fails to pay their reappointment fee for two years, what steps must they follow to become eligible for re-registration?

A

The QME must take and pass the QME Competency Examination.

478
Q

List five scenarios that might result in disciplinary action being taken against a QME.

A

Self-referral (the QME tells injured workers to get treatment through the QME’s private medical practice).Ex Parte communications.Lack of availability for evaluation appointments within a reasonable time period(60 days).Submitting late reports.Prepares reports that are not up to standard.

479
Q

How should courts interpret workers’ compensation laws in California?

A

Liberally.

480
Q

What is the reason behind the courts’ liberal interpretation of California’s workers’ compensation laws?

A

With the purpose of extending work-comp laws’ benefits for the protection of persons injured in the course of their employment.

481
Q

When is an evaluation for permanent disability typically conducted?

A

When an injured worker is permanent and stationary (also known as maximal medical improvement, MMI).

482
Q

How is the term ‘permanent and stationary’ defined?

A

When the worker’s condition has reached maximal medical improvement (M.M.I.); the employee’s condition is well stabilized and is unlikely to change substantially within the next year, with or without medical treatment.

483
Q

What are the two criteria that establish permanent and stationary status?

A

The worker’s condition has reached maximum medical improvement (MMI).The worker’s condition is unlikely to substantially change within the next year with or without medical treatment.

484
Q

What are the five different categories of benefits under workers’ compensation?

A

Medical treatment.Temporary disability benefits.Permanent disability benefits.Death benefits.Supplemental job displacement benefits (vocational rehabilitation).

485
Q

If a QME learns that the injured worker’s impairment/disability resulted from non-work-related activities, should this be included in the QME report?

A

Yes. The QME should note this in the injured worker’s history. Apportionment may be required.

486
Q

If an injured worker was considered Permanent & Stationary before 1/1/2005, what three factors determine their Permanent Disability rating?

A

Subjective factors of disability.Objective factors of disability.Work restrictions.

487
Q

How is substantial evidence defined in formal terms?

A

Relevant evidence that a reasonable mind might accept as adequate to support a conclusion.

488
Q

What does substantial evidence mean in everyday language?

A

Reasonable medical probability.

489
Q

As evaluators, what role do they play in ensuring the quality of QME and AME reports used to resolve disputes?

A

The task of an evaluator is to provide a report which constitutes substantial evidence, and can be used to resolve disputes about medical issues.

490
Q

What percentage of certainty does a QME imply when using the term “reasonable medical probability”?

A

Reasonable medical probability is 51% or greater.

491
Q

How is a medical opinion defined?

A

Any opinion that a physician provides in speech or writing.

492
Q

For a medical opinion to qualify as substantial evidence, what must it be based on?

A

Reasonable medical probability.

493
Q

What criteria are used for making medical decisions during a QME evaluation?

A

Reasonable medical probability. The QME must have greater than 51% certainty of their opinion.

494
Q

How can a QME guarantee that their opinions meet the standard of “substantial evidence”?

A

A QME must conduct an adequate and comprehensive examination of the injured worker.

495
Q

What steps can a QME take to demonstrate that their written opinions in a medical report are substantial evidence?

A

The QME’s report will be considered substantial evidence if it sets forth the reasoning behind the QME’s opinions, not merely the conclusions.

496
Q

How much confidence or probability must a QME have to allocate apportionment?

A

Reasonable medical probability.

497
Q

List the four situations in which a QME’s medical opinion does not meet the criteria for “substantial evidence.”

A

Based on facts no longer germane.Based on inadequate medical histories or examinations.Based on incorrect legal theories.Based on guess, conjecture, surmise, and/or speculation.

498
Q

To qualify as substantial evidence, must a medical report include the reasoning behind the physician’s opinion rather than just conclusions?

A

Yes.

499
Q

When drafting a QME report, the QME refrains from using uncertain terms such as ‘possibly’ or ‘maybe.’ What alternative approach should they take?

A

Give direct and definite opinions supported by evidence and reasoning.

500
Q

What methods or criteria should a QME rely on to determine the credibility of physical exam outcomes and test results?

A

Entire range of the QME’s clinical skill and judgement.

Trove California QME Flashcards (2 decks)

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