QME Deck 2/2 Flashcards
Competency Exam
1
Q
What factors are considered to determine a suitable impairment rating for a specific injury or illness?
A
A rating that takes into account all impairments, not only the primary body part or organ system impacted, but the full impact of the illness and injury and its treatment.
2
Q
Why are physicians mandated by the Division of Workers’ Compensation (DWC) to use the AMA guidelines when evaluating impairments in injured workers?
A
To provide uniformity when calculating disability awards.
3
Q
How is the term ‘strict rating’ defined in the context of impairment evaluation?
A
A strict rating refers to the textbook, standard and customary use of the AMA guides to determine an impairment rating.
4
Q
If a QME identifies two different methods for calculating impairment for a specific injury, which one should be considered the most accurate for the report?
A
The method that gives the highest impairment rating is the most accurate rating.
5
Q
In a Permanent and Stationary (P&S) report, what does the abbreviation WPI represent?
A
Whole person impairment. This is the same as permanent impairment.
6
Q
What course of action should a QME take when an impairment is absent from the AMA guidelines?
A
Physicians are instructed to, “use clinical judgment, comparing measurable impairment resulting from the unlisted condition to measure impairment resulting from similar conditions with similar impairment.”
7
Q
What term is used when a QME compares an unlisted impairment to a listed one for the purpose of rating?
A
Rating by analogy.
8
Q
Which landmark case provided the legal foundation for using ‘rating by analogy’?
A
Almaraz-Guzman.
9
Q
In the context of rating by analogy or an Almaraz-Guzman analysis, does the derived impairment rating need to align closely with the original strict rating?
A
No, the rating by analogy can provide a different impairment rating.
10
Q
What criteria must be fulfilled when applying rating by analogy or conducting an Almaraz-Guzman analysis?
A
The QME must first calculate the strict rating. Then, an alternative impairment is calculated by analogy using an impairment value contained within a chapter of the AMA Guides. The more favorable rating is then the final rating.
11
Q
Is a rating by analogy or an Almaraz-Guzman analysis required for every case that is deemed Permanent and Stationary?
A
No.
12
Q
How does the AMA Guides define anatomic loss?
A
Damage to an organ system or body structure.
13
Q
What is the definition of functional loss according to the AMA Guides?
A
A change (decrease) in function for the organ or body system.
14
Q
What process was followed to establish the impairment criteria outlined in the AMA Guides?
A
Through scientific evidence, consensus of chapter authors, and medical specialty society recommendations.
15
Q
How many chapters of the AMA Guides are available for a QME to reference when rating an injured worker’s impairments?
A
As many as necessary to accurately rate permanent impairment.
16
Q
BONUS: When employing rating by analogy or an Almaraz-Guzman analysis, what four steps is a QME expected to follow?
A
Provide a strict rating per the AMA Guides.Explain why the strict rating does not accurately reflect the injured worker’s disability.Provide an alternate rating using the four corners of the AMA Guides.Explain why the alternate rating more accurately reflects the injured worker’s level of disability.
17
Q
What aspects must a QME assess and rate when assigning an impairment rating for an illness or injury, such as cancer?
A
The QME must evaluate and report all impairments resulting from the illness or injury including effects from treatment (impairments from chemotherapy, impairments from radiation, impairments from mastectomy).
18
Q
Is it appropriate for a QME to include subjective complaints when calculating impairment ratings?
A
Yes. The QME should collect a thorough history (subjective information) and perform a physical examination.
19
Q
What is the process for a QME to convert an upper extremity impairment into a whole person impairment rating?
A
Multiple the upper extremity impairment by 0.6 (memory aid: hands are worth more than feet).
20
Q
What method does a QME use to translate a lower extremity impairment into a whole person impairment?
A
Multiple the lower extremity impairment by 0.4 (memory aid: hands are worth more than feet).
21
Q
In the case of a worker who contracted HIV through their job, how should impairment be calculated once their HIV is well-controlled and they have reached maximum medical improvement?
A
This is a trick question. The QME should not assign impairment simply because of a diagnosis or a disease. There has to be impairment. In this case, whole person impairment would be 0%.
22
Q
For a worker with well-managed diabetes who has reached maximum medical improvement, what is the process for calculating impairment?
A
This is a trick question. The QME should not assign impairment simply because of a diagnosis or a disease. There has to be impairment.
23
Q
What was the purpose behind the development of the combined values chart in the AMA Guides?
A
So that multiple impairment calculations do not exceed 100% whole person impairment.
24
Q
If a worker has impairments affecting the right hand, left knee, and cervical spine, how should the QME calculate the total whole person impairment?
A
The QME should use the Combine Values Chart on page 604 of the AMA Guides.
25
BONUS: If impairments in both the left and right hands create a synergistic effect leading to a greater overall impairment than if different body parts were affected, what landmark case allows the QME to add these impairment ratings instead of combining them?
The Kite case. The Kite Case allows for the adding of impairment ratings for different body parts. “Adding” 8% and 4% results in 8% + 4%= 12%. “Combining” 8% and 4% (per the Combined Values Chart on page 604 of the AMA Guides) equals 10%. Notice how “adding” yields a higher impairment value.
26
How is the term 'chronic pain' defined in the context of impairment evaluation?
Any pain lasting more than 6 months after the date of injury.
27
If a QME does not identify any ratable impairments but the injured worker reports ongoing pain, is it permissible for the QME to assign up to 3% whole person impairment for chronic pain?
No. The pain “add-on” can only be added on top of ratable impairment.
28
If a QME assigns a 1% impairment rating but the worker experiences additional pain beyond that level, can the QME allocate up to 3% whole person impairment for chronic pain?
Yes. Because there is ratable impairment, 1 - 3% whole person impairment can be added on top of this.
29
When a QME determines that pain further restricts the injured worker's daily activities beyond the initial impairment rating, how much additional impairment may the QME assign as an 'add-on'?
1-3% whole person impairment.
30
If a QME concludes that an injured worker experiences chronic, severe pain not reflected in the impairment rating, what additional actions can the QME take?
The QME can assign 1-3% additional permanent impairment for pain.
31
If a QME finds no specific impairments but the worker reports headache pain, is it appropriate to assign an impairment rating for the headaches?
Yes. 1-3% whole person impairment can be added for headaches in the absence of other impairments; this is unique to headaches.
32
True or False: To ensure accuracy, a QME must consider how the impairment affects the worker's daily living activities when providing an impairment rating.
True.
33
Does the ability to work fall under the category of Activities of Daily Living?
No.
34
Senate Bill 899 (SB899) specifies that the most effective way to measure impairment is based on limitations to which aspects of the worker's functionality?
Activities of Daily Living (ADLs).
35
Before January 1, 2005, what standard or normal values were applied for assessing range of motion?
Packard Thurber’s “Estimated Average Normal” from 1960.
36
Starting January 1, 2005, what benchmarks must a QME use when comparing the range of motion in an extremity?
The QME must compare findings to the normal values found in the AMA Guides as well as to the opposite, unharmed/uninjured extremity.
37
What findings are categorized as 'objective findings' by the Division of Workers' Compensation (DWC)?
Lab and diagnostic tests, EMG/NCS electrodiagnostic testing, x-ray’s, MRI’s, CT’s.
38
If a worker exhibits minimal multilevel degenerative changes in a lumbar spine MRI but does not require treatment or face work or activity limitations, how should their lumbar spine impairment be assessed?
There is no ratable impairment. 0% Whole Person Impairment (WPI).
39
Identify four situations that result in a 100% total disability rating.
Loss of both eyes/ all sight.Loss of both hands/ complete use of hands.Total paralysis.Brain injury resulting in mental incapacity or insanity.
40
What are the responsibilities of an employer when it comes to the care of injured employees?
The employer is responsible for any disability directly caused by a work injury.
41
If a worker has a non-industrial condition that impedes recovery from an industrial injury, what obligations does the employer have?
The employer must pay for medical treatment for the non-industrial condition so that the injured worker can receive necessary medical care for the industrial injury. An example of this is if there is non-industrial, uncontrolled diabetes. If an injured worker needs an ankle surgery, but cannot until the diabetes is under control, then the employer must pay for the costs of helping to get the worker’s diabetes under control for surgery.
42
In the case of a morbidly obese worker who sustains an industrial knee injury and is required to lose weight before surgery, is the employer liable for covering the costs of a sleeve gastrectomy if it is deemed necessary?
Yes. The employer must pay for medical treatment for the non-industrial condition so that the injured worker can receive necessary medical care for the industrial injury.
43
Can an employer be held accountable for a worker’s disability that stems from factors that occurred either prior to or following an industrial injury?
No.
44
In what ways does apportionment serve to protect an employer from full liability?
So that the employer is not forced to pay for disability that is not the direct result of an industrial injury.
45
How is an employer's financial responsibility determined when a portion of the disability is work-related and another portion is not?
The employer shall only be liable for the percentage of permanent disability directly caused by the injury arising out of, and occurring in, the course of employment.
46
What is an alternative term used for apportionment?
“Causation of disability.”
47
What is a synonym for the term 'causation of disability'?
Apportionment.
48
How are the terms 'apportionment' and 'causation of disability' defined?
“Causation of disability”/ apportionment deals with a determination of accurate permanent disability and apportionment between industrial and non-industrial factors.
49
What are the valid factors upon which apportionment can be based?
“Causation of permanent disability.”
50
Is it mandatory for all QME reports to address apportionment to be deemed complete?
Yes, all QME reports must include an apportionment determination in order to be considered complete on the issue of permanent disability. However, there is a massive exception: it is unnecessary to provide an opinion about apportionment of permanent disability if the injured worker is not Permanent and Stationary/ has not reached MMI (Maximal Medical Improvement).
51
Must a QME discuss apportionment if the case has not yet reached a permanent and stationary status?
No. Only when the injured worker has reached a point of Maximal Medical Improvement (MMI) / Permanent and Stationary does apportionment need to be addressed.
52
Is it required to offer an opinion on the apportionment of permanent disability if the injured worker has not achieved a permanent and stationary condition?
No, it is unnecessary to provide an opinion about apportionment of permanent disability because the injured worker is not permanent and stationary.
53
During a QME evaluation, if the injured worker has not yet attained maximal medical improvement (MMI) or permanent and stationary status, should the QME still issue a report that includes opinions on apportionment and impairment rating?
No. Impairment (permanent impairment) and apportionment are only addressed at the time of maximal medical improvement (MMI) / Permanent and Stationary.
54
What methods can a QME utilize to determine apportionment?
By finding what approximate percentage of the permanent disability was caused by the direct result of injury arising out of and occurring in the course of employment and what approximate percentage of the permanent disability was caused by other factors both before and subsequent to the industrial injury, including prior industrial injuries.
55
In the case of a worker who sustained a lumbar spine injury resulting in permanent impairment, with an MRI revealing minimal multilevel degenerative changes and no history of lumbar spine issues, what percentage should be apportioned to pre-existing degenerative changes?
0%. It is speculation to assume there was impairment based on a diagnosis of “degenerative changes.” Simply having “degenerative changes” (diagnosis) does not mean that there was pre-existing impairment. Impairment is different than a diagnosis.
56
Who bears the responsibility of proving apportionment of the impairment?
The employer (also known as the Defense party, the Defense, the Defense Attorney, or the Adjuster).
57
When apportionment is necessary, is it the QME's role to manually subtract the apportioned amount from the overall impairment rating?
No. Apportionment is given as a stand-alone percentage.
58
If a QME identifies secondary psychological disorders, sleep disorders, and erectile dysfunction, but they are not catastrophic, can the QME still assign impairment ratings?
No.
59
If a worker sustained a left elbow injury in 2000 and was rated with a 10% whole person impairment, then reinjured the same elbow in 2020 with a 20% impairment rating, what steps should a QME take to determine apportionment?
The QME should assign apportionment because permanent impairments are presumed to last forever.
60
Is it within a physician's authority to apportion the cause of the injury?
No. The cause of the injury is irrelevant. (For instance, the fact that a faulty machine caused the injury is irrelevant). Causation of the injury deals with whether or not an injury occurred on the job).
61
Can a physician apportion the cause of the worker's permanent impairment or disability?
Yes. A physician must determine what portion of the permanent impairment/ disability, if any, was caused by factors other than the work injury.
62
Does a QME’s apportionment of the cause of injury constitute substantial evidence?
No, this report would not be substantial evidence. The cause of the injury is irrelevant and a QME may not apportion the “causation of the injury.”
63
If a worker drops a barrel on his foot at work due to a loss of grip in his previously injured right hand, can a physician apportion the injury to the pre-existing hand injury? Is this relevant to the QME's evaluation?
No. The cause of the injury is irrelevant and a QME may not apportion the “causation of the injury.”
64
Is a QME responsible for apportioning treatment?
No. Only permanent disability is apportioned.
65
Does a QME have the duty to apportion work restrictions?
No. Only permanent disability is apportioned.
66
True or false: Medical treatment for an injured worker should be apportioned based on both industrial and non-industrial factors, similar to how permanent disability is handled.
False.
67
What three elements must be included in a QME report for it to be considered substantial medical evidence regarding apportionment?
The QME report must disclose familiarity with the concepts of apportionment.The QME report must describe, in detail, the exact nature of the apportionable disability.The QME report must set forth the basis for the opinion/the reasoning.
68
What are the three essential components of a medical opinion in apportionment determinations?
Disclose familiarity (knowledge and understanding) with the concepts of apportionment.Describe in detail the exact nature of the apportionable disability.Set forth the basis for the opinion.
69
If a worker undergoes surgery for a work-related injury but suffers a stroke due to complications, and it is found that the worker had pre-existing conditions such as atrial fibrillation, strokes, TIA’s, CHF, hypertension, and diabetes, does the QME need to apportion the cause of the stroke to these pre-existing risk factors?
No. The cause of the injury is irrelevant. Remember, the stroke is the injury. Causation of the injury deals with whether or not an injury occurred on the job or, as in this case, if an injury is the result of a work-related injury.
70
When a worker suffers a stroke due to complications during surgery for a work injury, and the worker had pre-existing conditions like atrial fibrillation, previous strokes, TIA’s, CHF, hypertension, and diabetes, should the permanent disability from the stroke be apportioned to these pre-existing conditions?
Possibly. Apportionment would only be required if the previous strokes and TIA’s had resulted in permanent impairments to the injured worker (such as, the worker had leg weakness or the inability to use their left arm). The defense party would need to prove to the QME that the injured work had pre-existing permanent impairments. On the other hand, if injured worker’s present permanent disability was entirely the result of the stroke caused by the work-related surgery, then no apportionment is required. Simply having a medical history of “previous TIA’s” and “previous strokes” does not mean there was permanent impairment.
71
Can a QME apportion a work-related injury to risk factors if those factors made the injury more likely?
No. QMEs may not apportion to risk factors. Risk factors relate to the cause of an injury and the cause of the injury is irrelevant. A QME may not apportion the causation of the injury.
72
When determining if a work-related activity aggravated a pre-existing chronic medical condition, should a QME consider industrial risk factors?
No. Causation of injury is not based on risk factors but by whether or not industrial exposure contributed by 1% or more to the need for medical care.
73
A worker who sustained a lumbar compression fracture at work, with normal MRI and x-ray results one month prior, had the cause of the injury apportioned to their age of 98. Is this appropriate? Additionally, the QME apportioned permanent disability to risk factors; is this acceptable?
No and no. The QME may not apportion causation of the injury. In addition, the QME may not apportion permanent disability to risk factors, including to gender or age-based risk factors. A factor that may increase the risk of a particular kind of injury or condition is not evidence that the factor actually caused a portion of an individual worker’s permanent disability.
74
Is it permissible for a QME to apportion permanent disability based on the worker’s increased risk of sustaining an injury?
No. QMEs may not apportion permanent disability based on risk factors. Risk relates to chance of an injury occurring (and this is related to causation of the injury). Risk of injury is not the same as cause of disability. “Apportionment must be based on actual evidence as to the individual worker, not based on categorical risk factors and assumptions based on those factors.” Apportionment of permanent disability must be based on actual evidence as to the individual worker, not based on categorical risk factors and assumptions based on those factors.
75
If a worker with a pre-existing lumbar compression fracture suffers a work-related lumbar compression fracture in the same vertebral body, and the QME apportions the permanent disabilities to the pre-existing condition that weakened the bones, is this apportionment appropriate?
Yes. There is evidence that a pre-existing condition contributed to the permanent disability/ impairment.
76
Provide examples of categories that are protected against discrimination.
Gender, age, race, religion, sexual preference, whether or not the worker is represented by an attorney, and national origin.
77
Is it acceptable to reduce a worker's permanent disability compensation due to discrimination?
No. QMEs are required to provide medical opinions that are fair, and partial, and based on their best medical judgment.
78
Provide an example of unlawful apportionment based on an age-related risk factor.
“An injured worker, 1 year prior to the work-injury, had a normal lumbar spine Xray and normal lumbar spine MRI. Due to a work-injury, the worker now has permanent disability. On the basis that the worker was 80 years old, 50% of his permanent disability to his spine is nonindustrial and 50% is work-related.”
79
What makes apportionment to an age-based risk factor illegal?
Because there is no evidence that there was a pre-existing medical condition that were causing permanent impairments.
80
Offer an example of improper apportionment based on gender-related risk factors.
“On the basis that the worker is 60 and postmenopausal, 50% of her permanent disability for her heart is nonindustrial and 50% is related to the work-injury.”
81
Why is it illegal to apportion based on gender-related risk factors?
Because there is no evidence that there were pre-existing medical conditions that were causing permanent impairments.
82
If a 98-year-old worker sustains an L4/5 disc herniation with radiculopathy at work, but medical records show a previous herniation at the same location from another job, what should the QME consider when determining apportionment, and what is irrelevant?
The worker’s age should have no bearing on apportionment; it is illegal to discriminate based on age. The fact that the worker had a pre-existing condition is key and absolutely should be apportioned. For example: “25% of the workers disability is related to pre-existing radiculopathy. 75% of the workers disability is related to the injury from work.”
83
How is a dispute over compensability, also referred to as Labor Code section 4060, defined?
This is a dispute over whether work caused an injury recognized under the workers’ compensation laws of California. This is also known as a dispute over “causation of the injury.”
84
If a worker asserts that an injury happened at work but the claims administrator denies the claim, stating the injury was not work-related, is it possible to request a QME?
Yes. This is a dispute over compensability (also known as Labor Code section 4060). This is also known as a dispute over “causation of the injury.”
85
Under what circumstances is Labor Code section 4060, involving a dispute over compensability, applied?
Any time after the claim form is filed, but before the claim or any body part has been accepted by the claims administrator.
86
After a claims administrator has accepted responsibility for any body part, can either party request a QME under Labor Code section 4060 concerning compensability?
No. Once the claims administrator has accepted any body part, a QME panel cannot be requested based on compensability (also known as Labor Code section 4060).
87
When a worker claims two injuries and the claims administrator accepts one but disputes the work-relatedness of the other, can a QME panel be requested under Labor Code section 4060 for compensability?
No, because the claims administrator already accepted 1 body part. Once 1 body part is accepted as a work-injury, a QME panel cannot be requested based on compensability (also known as Labor Code section 4060).
88
If a worker claims two injuries, and the claims administrator only accepts one and rejects the second as non-work-related, preventing a QME panel request under Labor Code section 4060, what alternative methods can be used to resolve the dispute?
Once 1 body part is accepted as a work-injury, a QME panel cannot be requested based on compensability (also known as Labor Code section 4060). Thus, the dispute regarding compensability of the 2nd injured body part must be resolved under Labor Code section 4062 (the Labor Code’s “catch-all” section).
89
If a QME performed an evaluation to address a compensability issue under Labor Code section 4060, but the claims administrator had already accepted one of the four body parts claimed to be injured, was the QME appropriately requested for compensability?
No. The QME should not have been requested for compensability (also known as Labor Code section 4060) because the claims administrator had already accepted 1 body part.
90
If a QME panel was requested for compensability, a QME was selected, an evaluation took place, and a report was issued, but it was later discovered that the claims administrator had already accepted one body part as work-related, who is responsible for the QME fees?
Neither party is liable for paying the QME fees. A QME panel should not be requested based on compensability (also known as Labor Code section 4060).
91
When a claims administrator is uncertain whether the employer is responsible for an injured worker's injury, what two actions must the claims administrator take for an unrepresented injured worker?
Send the injured worker a notice that the claim is denied and they may or may not request a QME.Send the injured worker a notice that the claims administrator requests an examination to further investigate compensability (Labor Code section 4060).
92
If a QME discovers that an injured worker is claiming symptoms that have been present for over a year before filing a Workers’ Compensation claim, is the worker eligible to have the claim accepted as work-related?
Yes.
93
For an injured worker claiming a cumulative trauma industrial injury, what is considered the date of injury?
Date of injury in cases of cumulative injuries is that date upon which the employee first suffered disability therefrom and either knew, or in the exercise of reasonable diligence should have known, that such disability was caused by his/her present or prior employment.
94
When an injured worker, who has held multiple similar jobs in succession as a full-time logger, realizes they have sustained a work-related injury that requires treatment, how does the QME establish the Date of Injury?
The date when the injured worker first realized there was a work-related injury.
95
If an injured worker, who has held multiple similar jobs as a full-time logger, has a Date of Injury associated with their last employer but the injury is a result of cumulative trauma, could the previous employers be liable for the impairment/permanent disability, and how should the QME address this?
Yes, prior employers may be liable for the impairment. This should be addressed at the time the worker reaches maximal medical improvement/ Permanent and Stationary with apportionment of permanent disability/impairment. Of note, the defense has the burden of proof to show that the injured worker had pre-existing permanent impairments.
96
If an off-duty employee was asked by her supervisor to give visitors a tour of the factory and slipped, sustaining an injury, is there industrial causation, and if so, what is the nature of the causation?
Yes. The injury Arose Out of Employment (A.O.E.).
97
If an on-duty employee was injured by a saw while performing his regular job of cutting trees, is there industrial causation, and if so, what is the nature of the causation?
Yes. The injury occurred during the Course Of Employment (C.O.E.).
98
If an off-duty employee was injured in a car accident while driving home, is there industrial causation, and if so, what is the nature of the causation?
No. A normal commute to and from work is not work-related.
99
If an injured worker contracts HIV while on the job, what protections must be provided to the injured worker?
Maintain a fictious name file with a Workers’ Compensation Judge.Follow all usual medical confidentiality laws.
100
If a worker sustains a paper cut and sees a doctor, who then clears the worker to return to work without restrictions, how is this situation categorized, and should a formal claim be filed?
This is considered a minor first aid incident. No claim should be filed. First aid involves one-time treatment and follow up visits.
101
What is the minimum requirement for a claim to be considered compensable?
If an industrial injury triggered the need for medical care and treatment by 1%, then it’s a compensable claim.
102
How is the term 'aggravation' defined?
An aggravation is defined as additional impairment above and beyond the worker’s baseline level of impairment. Stated another way, a medical condition may be present already, but some event/ (work) exposure makes it worse.
103
What are three essential categories of information required to assess whether work caused industrial aggravation of a chronic, pre-existing medical condition?
An understanding of the natural history of the pre-existing medical condition.A chronological listing of all diagnostic data related to the pre-existing medical condition.A chronological history of symptoms and functional limitations related to the pre-existing medical condition.
104
If an injured worker previously sustained an injury resulting in permanent impairment/disability and then experienced an aggravation of that injury, is this considered a compensable claim, or should the QME conclude that the aggravation is non-industrial?
An aggravation is defined as additional impairment above and beyond the worker’s baseline level of impairment. Thus, the injury made the impairment at least 1% worse so this is a compensable claim.
105
If a worker's pre-existing medical condition was aggravated by work-related activities, is this injury compensable?
Yes. Under the Labor Code this is a work-related compensable injury.
106
How is the term 'exacerbation' defined?
An exacerbation or “flare up” is a temporary increase in symptoms that does not permanently increase the worker’s baseline level of pain.
107
If an injured worker, who had a previous injury resulting in permanent impairment/disability, experiences an exacerbation of that injury, is this a compensable claim, or should the QME determine that the exacerbation is non-industrial?
An exacerbation is a temporary increase in symptoms. Thus, this flare up injury is not a compensable claim.
108
Within the workers' compensation system, is the act of proving or disproving a contested claim considered a valid 'medical-legal expense'?
Yes.
109
Can a compensable injury result from both a specific event and cumulative trauma within the same case?
Yes.
110
Can a QME be requested when there is a dispute regarding the existence or extent of permanent disability?
Yes. This is a permanent disability dispute (also known as Labor Code section 4061).
111
Can parties request a QME if there is a disagreement over the necessity of future medical care?
Yes. This is a permanent disability dispute (also known as Labor Code section 4061).
112
Is it possible for future medical care to extend beyond two years?
Yes.
113
When a QME is the first physician to determine that a worker has reached Permanent and Stationary status during the QME evaluation, what additional requirements must be met?
The QME must complete the Return-to-Work and Voucher Report and serve it to the claims administrator and the employee along with the final QME report.
114
What factors or conditions does a QME evaluate?
The QME rates permanent impairment. The QME provides permanent impairment ratings.
115
What else does a permanent impairment rating determine?
A determination regarding the extent of injury.
116
Is a QME responsible for providing permanent disability ratings?
No, the QME does not rate permanent disability. The QME does not provide permanent disability ratings. It is important to remember that permanent disability and permanent impairment are two different things.
117
Is it within a QME's responsibilities to rate permanent disability?
No, the QME does not rate permanent disability. The QME does not provide permanent disability ratings. It is important to remember that permanent disability and permanent impairment are two different things.
118
When a QME determines that an injured worker has reached maximal medical improvement (MMI) / Permanent & Stationary status and the date of injury occurred after January 1, 2005, what standard must be used for the impairment rating?
The AMA Guides 5th edition. (No other edition may be used.)
119
Is a QME with a specialty in acupuncture permitted to issue opinions on impairment ratings and permanent disability?
No.
120
If an Acupuncture QME is presented with contested issues of impairment and permanent disability, how should they proceed?
The Acupuncture QME should answer all issues within their scope but request another QME address permanent disability and provide ratings for permanent impairments.
121
What is the critical date to keep in mind when determining the standard a QME should use for conducting an impairment rating?
Whether the date of permanent and stationary was before or on/after January 1, 2005.
122
What guidelines are used to rate impairment for an injured worker who reached Permanent and Stationary status before January 1, 2005?
The 1997 Permanent Disability Rating Schedule (P.D.R.S.).
123
What method is used to determine impairment ratings for injuries that occurred before January 1, 2005?
April 1997’s Permanent Disability Rating Schedule.
124
Do the impairment ratings found in the AMA Guides assume that the injured worker’s injuries are permanent and stationary or that they have reached maximal medical improvement (MMI)?
Yes. These are permanent impairment ratings.
125
What criteria are used to rate impairment for injuries that occurred on or after January 1, 2005 and have reached Permanent and Stationary status?
The American Medical Association (A.M.A.) Guides to Evaluation of Permanent Impairment 5th edition (abbreviated as AMA Guides).
126
What standards are applied to determine impairment ratings for injuries occurring on or after January 1, 2005?
AMA Guides to the Evaluation of Permanent Impairment, 5th Edition.
127
If an injured worker is approaching Permanent and Stationary status but the QME requires additional tests and imaging studies to issue an impairment rating, what steps should the QME take?
It is legal for the QME to decline issuing a permanent impairment rating until the tests and imaging studies are completed and then reported to the QME.
128
If an injured worker requests additional medical treatment, can the QME resolve this dispute regarding the need for current treatment?
No. This would be resolved through the Independent Medical Review process or the Utilization Review process.
129
As of what date, irrespective of the date of injury, should QMEs cease to resolve disputes concerning the current need for medical treatment?
July 1, 2013.
130
True or false: Beginning January 1, 2013 for new injuries, and July 1, 2013 for all injuries, QMEs no longer resolve disputes related to the current need for medical treatment.
True.
131
When a worker is represented by an attorney, how many days does either party have to object to the medical determination made by the injured worker’s primary treating physician (PTP)?
20 days.
132
If a worker is unrepresented, how many days does either party have to object to a medical determination made by the injured worker’s primary treating physician (PTP)?
30 days.
133
Is it permissible for a party to request a QME in cases of dispute regarding whether an injured worker is temporarily disabled?
Yes. This falls under Labor Code Section 4062 (the Labor Code’s “catch-all” section).
134
Can a QME be requested to address disputes concerning whether or not an injured worker has work restrictions?
Yes. This falls under Labor Code Section 4062 (the Labor Code’s “catch-all” section).
135
What is the intended purpose of prophylactic work restrictions?
To ensure that the injured worker does not sustain further injury.
136
Can a QME be requested in cases of dispute over whether new or additional disability has developed following the original injury?
Yes. This falls under Labor Code Section 4062 (the Labor Code’s “catch-all” section).
137
Is it permissible for a party to request a QME to resolve a dispute about whether an injured worker's condition has reached Permanent and Stationary status or MMI?
Yes. This falls under Labor Code Section 4062 (the Labor Code’s “catch-all” section).
138
Can a QME be requested to resolve disputes regarding whether a newly added body part is a compensable consequence of the industrial injury?
Yes. This falls under Labor Code Section 4062 (the Labor Code’s “catch-all” section).
139
Under LC4662, how many days are payers given to settle a medical-legal expense?
60 days.
140
If an injured worker requests additional medical treatment, can the QME resolve the dispute under the 'catch-all' provision?
No. This would be resolved through the Independent Medical Review process or the Utilization Review process.
141
Can disputes concerning current medical care be resolved through a QME under Labor Code section 4062?
No. Senate Bill 863 (SB863) established the Independent Medical Review system to deal with current medical care disputes.
142
If an injured worker believes that their current treatment was wrongfully denied by insurance, can this dispute be resolved by a QME?
No. Senate Bill 863 (SB863) established the Independent Medical Review (I.M.R.) system to deal with current medical treatment disputes.
143
Can an injured worker bring a dispute to a QME if they believe that their current treatment has been delayed by the insurance company?
No. Senate Bill 863 (SB863) established the Independent Medical Review system to deal with current medical treatment disputes.
144
If an employee disagrees with substantial aspects of their primary treating physician's disability evaluation, can the employee request a QME evaluation?
Yes.
145
If an employer disagrees with significant elements of the primary treating physician's disability evaluation for an injured worker, can the employer request a QME evaluation?
Yes.
146
Can an employer request a QME evaluation if they disagree with substantial portions of the primary treating physician's disability evaluation for an injured worker?
Yes.
147
Who is eligible to request a QME?
An employee (and their attorney, if any) or an employer (and their attorney, if any).
148
Under what circumstances is it permissible for a licensed physician who is not a QME to serve as an AME?
When an injured worker is represented by an attorney and both parties (the injured worker’s attorney and the insurance adjuster/defense attorney) agree to use that physician.
149
If a doctor, who is also a QME, treats a patient and the patient later suffers a contested work injury, is the doctor allowed to act as the QME in this case?
No.
150
After a QME evaluates an injured worker, the worker voluntarily selects the QME as their primary treating provider (PTP). Can the doctor later perform a QME re-evaluation for the same worker?
No. The injured worker will need to select a different QME.
151
Which organization in California is tasked with creating a panel of three QME physicians?
The Division of Workers’ Compensation (DWC) Medical Unit.
152
How many doctors are included in a QME panel?
Three.
153
How is the term 'unrepresented injured worker' defined?
An injured worker who is not represented by an attorney.
154
Is it possible for an unrepresented injured worker to resolve a medical dispute by using an Agreed Medical Evaluator (AME)?
No. An unrepresented injured worker cannot be offered and cannot accept an offer to resolve a medical dispute using an AME.
155
When an injured worker is unrepresented, which party has the initial right to request a QME panel using form 105?
The injured worker. Remember, there is inherent power in requesting a QME panel because the party that completes the request gets to select the specialty of the QME.
156
For an unrepresented injured worker, who has the first opportunity to choose the specialty of the physicians on the QME panel?
The injured worker. This selection is a part of requesting a QME panel (form 105).
157
When is a claims administrator allowed to request a QME panel (form 105) for an unrepresented injured worker?
The claims administrator may submit the QME request form (form 105) when the employee has not submitted the QME request form (form 105) within 10 days after the employer has furnished the QME request form (form 105) to the employee and requested the employee to submit the QME request form (form 105).
158
If a claims administrator provides form 105 to an unrepresented injured worker and asks them to submit it to request a QME panel, what happens if the worker does not submit the form within 10 days?
The claims administrator can request a QME panel by submitting form 105 and designate the specialty of the QME.
159
Why is it important which party formally submits the request for a QME panel using form 105?
The party submitting the form (form 105) to request a QME panel gets to choose the specialty of the QME.
160
After a QME panel is issued, how many days does an unrepresented injured worker have to choose a physician from the panel, schedule the QME evaluation, and notify the claims administrator of their selection and appointment?
10 days.
161
What three actions must an unrepresented injured worker complete within 10 days of receiving a QME panel?
Select one of the 3 physicians from the panel.Make an appointment with the physician for the examination/evaluation.Inform the claims administrator of the name of the physician and the date/time of the appointment.
162
What are the consequences if the Division of Workers’ Compensation (DWC) does not generate a QME panel for an unrepresented injured worker?
The unrepresented injured worker can obtain an evaluation from any QME within a reasonable geographical area.
163
What happens if an unrepresented injured worker does not notify the claims administrator about their selected physician from the QME panel within 10 days of receiving the panel?
The claims administrator may select the QME to perform the evaluation.
164
What are the consequences if an unrepresented injured worker fails to inform the claims administrator of their scheduled appointment date?
The claims administrator may arrange the QME appointment.
165
If an unrepresented employee undergoes a comprehensive medical-legal evaluation under Labor Code section 4062.1 (a) and later gains legal representation, are they entitled to an additional evaluation?
No. He or she shall not be entitled to an additional QME evaluation.
166
How is a 'represented injured worker' defined?
An injured worker who has retained an attorney.
167
From what date are panel QME evaluations available to represented workers for disputes related to an injury or a claimed injury?
January 1, 2005.
168
Under what conditions can represented workers resolve a dispute by agreeing to use an Agreed Medical Evaluator (AME)?
At any time.
169
What must occur for represented workers before they can file form 106 to request a panel of QMEs?
First, a “request for a QME” notification must be served on the opposing party to alert the opposing party. Filing form 106 is the second step to generate a panel of 3 QMEs.
170
After a request for a QME is served to the opposing party, which party in a represented worker's dispute is allowed to submit and file form 106 to request a panel of QMEs?
Either party can submit the form (form 106) to request a panel of QMEs.
171
If party A mails a request for a QME to resolve a dispute with party B, how many days must party A wait before filing form 106 to request a panel of QMEs?
10 days.
172
Once the Medical Director assigns a QME panel for represented workers, what actions can each party take?
A QME panel has 3 physicians. Each party can “strike” one physician from the list. The remaining QME shall serve as the medical evaluator.
173
How many days do the injured worker and their party have to remove a QME from the panel of three QMEs created by the DWC?
10 days.
174
How many days does the employer and their party have to eliminate a QME from the list of three QMEs provided by the DWC?
10 days.
175
What occurs if a party does not remove a physician within 10 days after a QME panel is assigned for represented workers?
The opposing party may exercise the right to strike a second physician.
176
If a represented employee has undergone a comprehensive medical-legal evaluation and later becomes unrepresented, are they eligible for another evaluation?
No.
177
Is it possible for represented workers to request a QME if the parties have already agreed to refer the case to an AME or have already submitted it to one?
No.
178
Once a QME panel is issued and a QME is selected, how many days does the chosen QME have to schedule an appointment to see the employee after receiving a request?
60 days.
179
Apart from the specialty, what factors influence which QME physicians are randomly selected for a QME panel?
The proximity of the worker’s home address with the QME’s office address.
180
Under what circumstances can a QME appointment be scheduled more than 60 days after the request date?
An appointment may be scheduled beyond 60 days of a request for an appointment if the party who has the right to schedule an appointment is willing to accept an appointment up to 90 days from the date of the request.
181
After an appointment is scheduled, what document is the QME required to submit?
The QME must submit the QME Appointment Notification form (Form 110).
182
After an appointment is confirmed, within how many business days must the QME submit the QME Appointment Notification form (Form 110)?
5 business days.
183
Who should receive the QME Appointment Notification form (Form 110) once it is completed?
The employee, the employee’s representative (if there is one), the employer or the claims administrator, and the latter’s representative.
184
What is the purpose of the QME Appointment Notification form?
The appointment notification form serves as the notice of an appointment and is also the notice for sending medical records and other information to the QME in connection with the examination.
185
What are the consequences if a QME does not submit the QME Appointment Notification form?
The failure is a cause for the issuance of a replacement QME panel (the selected QME loses the case gets replaced).
186
Is information about an interpreter included in the QME Appointment Notification form?
The QME Appointment Notification form shall state whether a state-certified interpreter is required and specify the language that is necessary.
187
If a QME cancels a scheduled appointment and verbally notifies the injured worker, what action must the QME take next?
A verbal cancellation / telephone call must be followed by a written confirmation to both parties.
188
Who is in charge of organizing and covering the costs of the interpreter for a QME evaluation?
The employer / defense party.
189
How is the term 'medical-legal cost' defined?
Specified services incurred to prove or disprove a contested case.
190
How many days before the appointment can the QME evaluator or any party cancel the appointment?
6 business days prior to the appointment date.
191
What steps must an evaluator, either QME or AME, follow when canceling a scheduled evaluation?
The evaluator must advise the parties in writing the reason for the cancellation. The evaluator must reschedule the appointment to a date within 30 calendar days of the date of cancellation (the rescheduled appointment date may not be more than 60 calendar days from the date of the initial request for an appointment, unless the parties agree in writing to accept the date beyond the 60 day limit).
192
If a QME cancels a scheduled evaluation, within how many calendar days must the appointment be rescheduled?
30 calendar days.
193
What is the required procedure when a party or their attorney cancels a QME evaluation appointment?
The cancellation can be made verbally to the QME physician and then must be followed by a written confirmation letter that is faxed or mailed to the QME physician within 24 hours of the verbal cancellation.
194
Is an injured worker responsible for missed appointments when a QME evaluation is canceled for a valid reason?
No.
195
Which authority is responsible for resolving disputes over whether a QME evaluation appointment cancellation made fewer than six days before the appointment was justified?
The Worker’s Compensation Appeals Board (W.C.A.B.).
196
Who is responsible for taking disciplinary action against a QME for violations related to appointment cancellations?
The Administrative Director.
197
Is an evaluator permitted to cancel an appointment due to not receiving the necessary medical records?
No, unless the evaluation is by a psychiatrist or psychologist under certain stipulations.
198
Can an evaluator choose to schedule or not schedule an appointment depending on whether the employee has legal representation?
No, the evaluator must schedule appointments without regard to whether or not an employee is represented.
199
How should communications between the parties and a QME be managed before the examination takes place?
All communications prior to an examination by the parties with a QME must be in writing and served on the QME at the same time as the opposing party.
200
Who is responsible for providing the QME with all records created or maintained by the employee’s treating physician(s)?
Any party.
201
Who may submit other medical records, such as prior treatment information relevant to the medical issue in dispute, to the QME?
Any party.
202
Which party may provide non-medical records, including films and videotapes relevant to the determination of medical issues in dispute, to the QME?
Any party.
203
Should a QME rely on the accuracy of the information contained in the medical records they receive?
Yes.
204
If a letter is sent to the QME before an evaluation, indicating that compensability is the issue in dispute, which party is responsible for providing this information to the QME?
Any party.
205
How many days in advance must a party share information with the opposing party before providing it to the QME?
20 days.
206
Once party B receives non-medical records from party A, how many days do they have to object and prevent those records from being sent to the QME?
10 days.
207
Is it permissible to send a QME any medical/legal report that has been rejected as untimely by a party?
In no event should the QME be sent this information.
208
Can a QME receive an evaluation or consulting report that has been removed or deemed inadmissible by a WCAB administrative law judge?
In no event should the QME be sent this information.
209
Is it allowable for a QME to receive any medical report, record, or other material that has been deemed inadmissible by a WCAB administrative law judge or found inadequate as a matter of law?
In no event should the QME be sent this information.
210
What actions can the QME take if a party does not provide relevant medical records deemed necessary for a comprehensive medical-legal evaluation?
The evaluator may contact the treating physician or other health care providers to obtain such record(s).
211
What steps should the evaluator take if a party fails to supply necessary medical records within 10 days after the evaluation date, and the evaluator cannot obtain the records?
The evaluator shall note in the report that the records were not received within 10 days after the date of the evaluation. The evaluator shall complete and serve the report within 30 days of the evaluation to comply with the usual deadline.
212
When may the QME submit a supplemental evaluation if they initially filed a report without the necessary records, which were later provided?
Upon request by either party or the Worker’s Compensation Appeals Board (WCAB).
213
When parties choose an AME to resolve a dispute, who determines what information will be provided to the AME?
Both parties must agree on the information that is sent to the AME.
214
If the history gathered by the QME from the injured worker differs from the medical records, how should the QME address this in the report?
The QME should issue opinions based on both forms of the history and then let a WCAB (Workers’ Compensation Appeals Board) judge decide the correct form of the history.
215
True or false: A QME should not gather information about how the injured worker commutes, their lost wages, or their family members’ work histories. Instead, the QME should focus on collecting details about the events immediately following the work injury.
True.
216
How is 'ex parte communication' defined?
Any communication, written or oral, by one party, or a party’s representative, with the QME outside the presence of the opposing party.
217
Is ex parte communication allowed?
Ex parte communication is forbidden in connection with the QME.
218
Why is ex parte communication prohibited?
To avoid possible covert influence by one party, or the suggestion of covert influence by one party, which would prejudice the impartial, neutral QME.
219
Does the ban on ex parte communication apply to both spoken and written interactions by the employee during the evaluation or when requested by the QME in connection with the evaluation?
No. Oral and written communications between the injured worker and the QME are allowed. Filling out written forms requested by the QME is allowed. A history collected in connection with the examination is allowed.
220
What recourse does the aggrieved party have if a party illegally communicates with the QME or if the QME communicates improperly with one of the parties?
The aggrieved party may elect to terminate the medical evaluation and seek a new QME. Or, the aggrieved party may elect to proceed with the QME evaluation.
221
In a medical-legal report, what three elements should a QME include to demonstrate that no ex parte communication occurred?
All information used in forming opinions.All information received from the parties.All information reviewed while preparing the report.
222
Is a QME allowed to contact and consult with the injured worker’s treating physician if the necessary medical records have not yet been received?
Yes, this is allowed. Even if the medical records are received, this is allowed. The QME must note the name of the treating physician and note any new or additional information received.
223
Can a party communicate directly with the QME for administrative purposes such as scheduling, verifying whether medical records were sent, or addressing missed appointments (non-substantial issues)?
No, a party is never allowed to privately communicate with the QME. All communications by a party with the QME shall be in writing and sent simultaneously to the opposing party when sent to the QME.
224
What consequences face a party that engages in prohibited ex parte communication?
The party shall be subject to being charged with contempt before the WCAB (Workers’ Compensation Appeals Board) and shall be liable for the costs incurred by the wronged party as a result of the prohibited communication.
225
Is it legally permissible for a QME to discuss administrative matters such as confirming appointments or verifying medical record submissions with the attorneys, insurance adjuster, or injured worker?
No. Absolutely no ex-parte is allowed for a QME. The Court of Appeal took a strict approach to ex parte communication stating that even for procedural matters like setting appointment dates, ex parte communications is prohibited for a QME. All communications by a party with the QME shall be in writing and sent simultaneously to the opposing party when sent to the QME.
226
Is it permissible for an AME to communicate with the attorneys, insurance adjuster, or injured worker regarding administrative issues such as confirming appointments or verifying the submission of medical records?
Yes. Labor Code section 4062.3(f) allows oral or written communications with an AME physician or the physician’s staff relative to non substantive matters such as the scheduling of appointments, missed appointments, the furnishing of records and reports, and the availability of the report.
227
Is it legal for a QME to contact the injured worker’s primary treating provider (PTP) for additional information about the worker?
Yes, the QME can reach out however, the QME must disclose the contact and the nature of information received in the QME report.
228
Under what circumstances is ex parte communication allowed?
Never.
229
Can an evaluator request or accept compensation or anything of value from any source that could create a conflict of interest with their duties?
No.
230
Under what conditions does a conflict of interest arise?
A conflict of interest exists when an evaluator has a connection of some sort—personal, financial, or otherwise—with any of the parties involved in a dispute, a connection which may interfere with an objective evaluation.
231
When is a QME allowed to disqualify themselves due to a conflict of interest?
Whenever the evaluator has a relationship with a person or entity in a specific case, including doctor-patient, familial, financial or professional, that causes the evaluator to decide it would be unethical to perform a comprehensive medical-legal evaluation examination or to write a report in the case.
232
What actions should a QME take when they discover a conflict of interest?
Disclose the nature of the conflict in writing to the parties within 5 business days of becoming aware of the conflict.
233
What occurs when a conflict of interest is disclosed in the case of an unrepresented injured worker?
The parties are required to obtain a new QME.
234
If a QME selected from a panel realizes they have previously treated the injured worker, under what circumstances can they continue with the evaluation?
Never. A physician can never serve as QME for a case that they previously treated the injured worker.
235
In represented cases, what choices do the parties have when a conflict of interest is revealed?
The parties have the option of waiving the evaluator’s conflict of interest or, if they do not agree to waive the conflict, then to replace the evaluator’s name on the panel or request a new panel.
236
Who resolves disputes regarding whether a conflict of interest could compromise the integrity and impartiality of the evaluation?
A Workers’ Compensation Appeals Board (WCAB) administrative law judge.
237
If a QME needs an MRI to be completed before issuing an impairment rating and wants to refer the injured worker to an MRI facility owned by their brother, what actions must the QME take?
The QME must file a Financial Conflict of Interest form with the Administrative Director before sending the referral.
238
What is the highest market value of gifts an evaluator can receive annually from a single source involved in California Workers’ Compensation?
$360.
239
What four things is a QME required to disclose to the injured worker during the evaluation?
That the injured worker may ask questions about any matter concerning the evaluation process.That the injured worker may discontinue the evaluation based on good cause such as discrimination, abusive or rude behavior, and instances where the evaluator request the worker to submit to an unnecessary exam or procedure.When required, the evaluator disclose probationary status and explain the circumstances.That the QME evaluation is for assessment and not treatment.
240
If the injured worker chooses not to ask questions regarding the evaluation process and does not raise objections during the exam, can they still object to the evaluation based on good cause?
No.
241
List three 'good cause' reasons that allow an injured worker to terminate a QME evaluation after it has started.
Discriminatory conduct towards the worker based on race, sex, religion, sexual preference.Abusive, hostile, or rude behavior demonstrating bias.Unnecessary examinations.
242
If an injured worker ends an examination citing good cause (section 40), and a WCAB judge later finds that no good cause existed, who is responsible for covering the evaluation costs?
The cost of the evaluation will be deducted from the injured worker’s award.
243
If a QME has someone, 'Sam,' who reviews and summarizes the medical records for a case, what are the QME’s obligations?
The QME must review Sam’s work (compare the summary with the raw medical records) and disclose that this activity assisted in production of the report. Additionally, the QME is solely responsible for interpreting the data. The QME can only bill for the time spent personally reviewing records.
244
Who can seek assistance from the Information and Assistance Unit of the Division of Workers’ Compensation (DWC)?
Unrepresented injured workers, represented injured workers, employers, attorneys, QMEs, etc.
245
What can an injured worker request to review during their QME evaluation?
The QME’s state medical license, the QME’s certificate to perform QMEs at that location, and the QME’s curriculum vitae.
246
Which party is responsible for covering the costs of medical reports generated from an exam that was terminated for good cause?
Neither party.
247
What is a QME’s ethical responsibility concerning the injured worker’s wait time on the day of the evaluation?
Applicants should not be made to wait for longer than 1 hour. If so, then the worker can leave and request a replacement QME panel.
248
What is a QME’s ethical obligation concerning the date of a report?
The report should be dated when it is completed.
249
What ethical responsibility does a QME have regarding the opinions expressed in their report?
The QME must opine only on areas which the QME is an expert.
250
What are a QME’s ethical obligations concerning appointment cancellations?
There should be no cancellations within 6 business days of an evaluation unless there is good cause. If a cancellation does occur by the QME, then a new appointment should be offered that is within 30 calendar days.
251
What conditions must a “Physician’s office” meet to conduct QMEs and AMEs?
Each physician’s office listed with the Medical Director must be located within California, be identified by a street address and any other more specific location such as a suite or room number, and must contain the usual and customary equipment for the type of evaluation appropriate to the QME’s medical specialty or scope of practice.
252
For how many days must a QME maintain a physician’s office once it is listed by the DWC medical unit as available for medical-legal evaluations?
180 days.
253
What ethical responsibility does a QME have regarding the cleanliness and professional appearance of their office?
The office must be clean and professional.
254
Where should Qualified Medical Evaluations take place?
In an office location that has been approved for QME examinations by the California Division of Workers’ Compensation (DWC).
255
Can the initial appointment location be changed, except in rare circumstances?
No. The initial appointment location can never be moved. (Remember, the physicians who were generated on a QME panel are based on proximity to the injured worker).
256
Are subsequent QME evaluations, including re-evaluations and follow-up visits, allowed to take place at different locations?
Yes, but only at locations that the QME has listed on the official DWC website.
257
What ethical responsibilities does a QME have in addressing issues raised in cover letters?
The pertinent issues should be addressed.
258
Is an evaluator obligated to begin or continue an evaluation with an injured worker (or their representative) if the worker uses abusive language, disrupts the office, is intoxicated, or is under the influence of medications impairing their ability to participate in the evaluation?
No. The evaluator shall state the facts supporting the termination of the evaluation process.
259
Even though questioning the integrity of an injured worker is inappropriate, should the QME present and clarify inconsistencies in the worker’s history in the QME report?
Yes.
260
How is face-to-face time defined?
Face-to-face time means only that time the QME is present with an injured worker during an evaluation.
261
What is the required minimum face-to-face time for neuromusculoskeletal evaluations?
20 minutes
262
What is the minimum amount of face-to-face time required for cardiovascular evaluations?
30 minutes
263
How much face-to-face time is required as a minimum for pulmonary evaluations?
30 minutes
264
What is the required minimum face-to-face time for psychiatric evaluations?
60 minutes
265
What is the minimum face-to-face time required for evaluations that are not neuromusculoskeletal, cardiovascular, pulmonary, or psychiatric?
30 minutes.
266
Where are the evaluation protocols located for injuries occurring on or after January 1, 2005?
In the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition (AMA Guides).
267
True or false: California has set protocols for evaluating injured workers in fields such as immunology, neuromusculoskeletal, cardiac, psychiatry, and pulmonary.
True.
268
When a QME conducts an evaluation with the assistance of an interpreter, what is classified as face-to-face time for billing purposes?
Face-to-face time means only that time the QME is present with an injured worker during the evaluation.
269
True or false: When a QME gathers history and conducts a physical exam, it is counted as face-to-face time, but time spent by the injured worker with a historian, completing paperwork, and performing diagnostic tests is not considered face-to-face time.
True.
270
If an injured worker wants to record the QME evaluation, is the QME required to permit this?
Yes, this is allowed.
271
If a QME wants the injured worker to undergo a diagnostic test to aid in the QME report (e.g., a knee x-ray to assess arthritis severity), is this permitted?
Yes, this is allowed but the QME must first get authorization from the Insurance (claims) Adjuster before writing an order for the diagnostic test.
272
Must the date and the street address of the completed examination be included in the body of the comprehensive medical-legal report?
Yes.
273
If the evaluator signs the report on a different date than when the examination was completed, what action must they take?
Sign the report on the date the report was completed. Enter the date the report was completed near the signature on the report.
274
Is the evaluator required to address all disputed medical issues stemming from injuries reported on claim forms before the employee’s QME evaluation appointment?
Yes, as long as the issues are within the evaluator scope of practice in areas of clinical competence.
275
What steps should the evaluator take when faced with disputed issues that fall outside their area of expertise?
At the evaluator’s earliest opportunity and no later than the date the report is served, the evaluator shall advise the parties in writing of any disputed medical issues outside of the evaluator’s scope of practice and area of clinical competency in order that the parties may initiate the process for obtaining an additional evaluation.
276
How is “preponderance of the evidence” defined?
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. When weighing the evidence, the test is not the relative number of witnesses, but the relative convincing force of the evidence.”
277
How can “preponderance of the evidence” be explained in simpler terms?
The party must prove that its position is more likely than not to be correct.
278
Who bears the burden of proof to demonstrate by a “preponderance of evidence” that an injury was work-related?
The injured worker.
279
Who carries the burden of proof to establish that an injury was intentionally self-inflicted?
The employer.
280
Who has the burden of proof in matters of apportionment regarding the cause of permanent impairment or disability?
The employer.
281
According to Labor Code section 4628, what declaration must be part of the QME’s report?
“I declare, under the 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 the 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.”
282
Once a QME report is completed, what steps should the QME take if new evidence or additional research leads to a change in their opinions?
The QME is permitted to change their mind even after a QME report is served. The QME would issue a Supplemental report explaining the new opinions.
283
Can a QME bill for time spent reviewing the AMA guides, ACOEM treatment guidelines, MTUS treatment guidelines, Labor Codes, or California Code of Regulations under the “research” billing category?
No.
284
How is the initial evaluation performed by a QME referred to?
A comprehensive medical-legal evaluation.
285
Who performs a subsequent QME evaluation when a clinical issue arises within the competency of the original QME-physician and that physician remains available?
The parties must return to the QME-physician who originally provided a medical opinion in the case.
286
Typically, how much more is an evaluator paid if chosen as an AME for a case?
Evaluating a case as an AME pays 25% more for that single case (compared to evaluating the case as a QME).
287
If an injured worker receives a medical evaluation from a doctor who is not their PTP, QME, or AME and submits the report to the QME, what action must the QME take?
While this report is inadmissible, the QME must issue a report commenting on the self-procured report.
288
When is a QME required to inform the DWC Medical Director of a future period of unavailability?
When the length of an unavailability period is 14 days to 90 days.
289
If a QME intends to be unavailable for 14 to 90 days, when must they notify the DWC Medical Director?
At least 30 days before the period of unavailability begins.
290
What occurs if a QME does not inform the DWC Medical Director at least 30 days before their planned period of unavailability?
The period of unavailability may begin 30 days from the date the DWC Medical Director learns of the unavailability.
291
What information must a QME provide to the DWC Medical Director when requesting unavailable status?
A list of any and all comprehensive medical–legal evaluation examinations already scheduled during the time requested for unavailable status and shall indicate whether each such examination is rescheduled or if the QME plans to complete the examination and report while in unavailable status.
292
What is the maximum number of days a QME can be unavailable during a calendar year?
90 days.
293
What are some examples of good cause for a QME to be unavailable?
Death or serious illness of an immediate family member, a sabbatical.
294
What should the parties do if a follow-up evaluation is needed that exceeds the original QME-physician's scope of practice or limitations?
The parties may request the issuance of an additional QME-physician by agreeing in writing on the need for an additional QME panel and on the specialty of the additional QME.
295
What is the deadline for submitting a comprehensive medical-legal evaluation report?
The report shall not be submitted in excess of 30 calendar days after the evaluation.
296
From the date of the evaluation, how many days does a QME have to submit their report?
30 days.
297
What are the consequences if a QME fails to timely serve a completed medical-legal evaluation report?
Either party may request a QME replacement.
298
What are some reasons for issuing a replacement QME panel?
The chosen QME cannot schedule an appointment within 60 days.The chosen QME’s report was untimely and the party objected after being served with the report.The evaluator who previously reported in the case is no longer available.The specialty chosen was inappropriate.1 or more of the QME’s on the panel does not practice in the specialty requested.The injured worker has changed his or her residence address since the QME panel was issued and prior to date of the initial evaluation of the injured worker.
299
What is the deadline for submitting a supplemental report?
The report shall be submitted and serve no more than 60 days from the date of request to the QME physician by a party.
300
Does a Supplemental Medical-Legal Report require examining the injured worker?
No.
301
Does a Supplemental Medical-Legal Report include face-to-face interaction with the injured worker?
No.
302
Is it possible for a supplemental medical-legal report to include a narrative discussing new records, test results, or videos?
Yes. The report shall be submitted and served no more than 60 days from the date of request to the QME physician by a party.
303
Is a face-to-face examination of the injured worker required in a QME re-evaluation?
Yes.
304
Does a QME re-evaluation involve creating a narrative report and reviewing new diagnostic tests, medical records, and/or sub-rosa videos?
Yes.
305
Within how many days after the evaluation must a QME re-evaluation report be served?
30 days.
306
Who is responsible for covering the payment for an evaluation if the report is submitted late?
Neither the employee nor the employer shall have any liability for payment for the medical evaluation and report which was not completed within time frame.
307
If a report is submitted late but the parties wish to accept it, what steps must be taken?
The employee and the employer must waive their right to a new evaluation and elect to accept the original (late) report.
308
Who is permitted to object to a QME’s report if it is submitted late?
The employer, the insurance (claims) adjuster, either party’s attorney, and/or the injured worker.
309
How long does a QME have to respond when an unrepresented injured worker files a Request for Factual Correction of an Unrepresented Panel QME Report?
The panel QME shall have 10 days after service of the request to review the corrections requested in the form and determine if actual corrections are necessary to ensure the factual accuracy of the report.
310
What are five examples that can be considered 'good cause' for a QME to request an extension to file a report?
Death in the QME’s family.Community disasters that disrupt the QME’s business.Medical emergency for the QME or the QME’s family.Natural disasters.Damage to the QME’s office.
311
How much additional time is a QME granted to submit a report when an extension for good cause is approved?
15 days. Note that the request for an extension must be filed within the usual report deadlines.
312
Can a QME request an extension if they are waiting for test results or medical records, and if so, how long is the extension for?
Yes, for 30 days. Note that the request for an extension must be filed within the usual report deadlines.
313
What is the maximum time limit allowed for extending an evaluation date?
The evaluator may request an extension from the Medical Director, not to exceed an additional 30 days.
314
After receiving notification of a deposition, how long does a QME have to schedule it?
Depositions must be scheduled within 120 days of the notice.
315
Who receives a completed report in the case of a represented injured worker?
The evaluator shall serve each report on the injured worker, their attorney, and on the claims administrator (if there is no claims administrator, then on the employer).
316
What must be sent after an evaluation and to whom in the case of an unrepresented injured worker?
The QME shall serve a completed QME Findings Summary Form as well as the report to the injured worker and the claims administrator (if there is no claims administrator, then on the employer).
317
How is the term 'D.E.U.' defined?
Disability Evaluation Unit.
318
What are the responsibilities of the D.E.U.?
The DEU office issues summary disability ratings. “Raters” within the DEU convert permanent impairment ratings into summary disability ratings.
319
If a QME's report for an unrepresented injured worker addresses permanent impairment, disability, or apportionment, to whom else must the report be sent?
Besides serving the report to the unrepresented injured worker and the Insurance Adjuster (claims administrator), the evaluator shall serve the evaluation report on the Disability Evaluation Unit (D.E.U.) office.
320
For how long is a QME required to retain copies of all comprehensive medical-legal reports?
The QME should retain a copy of all reports for a period of 5 years from the date of the report.
321
Can a QME retain electronic copies of reports to meet the 5-year retention requirement?
Yes, as long as the electronic copy retained is a true and correct copy of the original.
322
How long must a QME retain billing records?
The QME should retain a copy of bills for 3 years.
323
If a worker is injured and wants to proceed with a claim, what steps should they take?
Fill out and give his employer the Division of Workers’ Compensation (DWC) “Claim Form” (DWC Form 1).
324
What actions should an employer take when a worker is injured and wishes to proceed with a claim?
Fill out the “Employer’s Report of Occupational Injury or Illness” (Form 5020).
325
What should the first occupational doctor do when treating a worker who is injured and wishes to proceed with a claim?
Fill out the “Doctor’s First Report of Occupational Injury or Illness” (Form 5021).
326
If a worker completes DWC form 1, 'Claim Form,' and submits it to their employer, how many days does the employer have to pass the form to the insurance adjuster or claims administrator?
1 working day. This is so that the injured worker can receive treatments in a timely manner.
327
After a worker submits DWC Form 1 'Claim Form' for a new injury, how long does the insurance adjuster or claims administrator have to respond?
90 days. If there is no response, then the claim is presumed to be industrial and the injured worker can have up to $10,000 in medical treatments.
328
What is the goal of medical treatment in the workers' compensation system?
To cure or relieve the effects of industrial injuries.
329
According to Labor Code 4600, what medical treatments are available to injured workers?
Medical, surgical, chiropractic, acupuncture, hospital treatment (and nursing), medicines, medical supplies, surgical supplies, crutches, orthotics, prosthetics.
330
What fee schedule is used to determine reimbursement for doctors treating injured workers?
The Official Medical Fee Schedule (OMFS).
331
How is the term 'treating physician' defined?
A physician who provides direct medical treatment to an employee which is reasonably required to cure or relieve the effects of an industrial injury.
332
What does 'primary treating physician (PTP)' mean?
This 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.
333
How many primary treating physicians is a patient allowed to have?
1
334
When an injured worker sees a primary treating physician (PTP) for a new injury, how long does the PTP have to send the 'Doctor’s First Report of Occupational Illness or Injury' to the relevant parties?
Within 5 days of the initial examination.
335
If a primary treating physician writes a report for an injured worker and there are no disputed or contested issues, can it be classified as a medical-legal report and billed accordingly?
No, this is not a medical-legal report. This should be billed under the Official Medical Fee Schedule (O.M.F.S.) and not the medical legal fee schedule.
336
What two treatment guidelines must doctors follow when treating injured workers to ensure their treatment is not denied by Utilization Review?
Medical Treatment Utilization Schedule (MTUS).American College of Occupational and Environmental Medicine (ACOEM).
337
What method should a primary treating physician use to obtain authorization from the insurance company for a treatment ordered for an injured worker?
A Request for Authorization (R.F.A.).
338
Under Senate Bill 899 (SB899), how many visits can an injured worker have with a chiropractor, physical therapist, and occupational therapist?
A maximum of 24 with each of these.
339
Before January 1, 2005, what was the maximum number of visits allowed for chiropractic, physical therapy, and occupational therapy?
There was no limit.
340
How often must a primary treating physician report on the injured worker’s condition using form PR-2?
45 days.
341
How is the term 'released from care' defined?
This is when a primary treating physician (PTP) determines that an injured worker’s injuries have fully resolved and do not require continued treatment. The injured worker has no permanent impairments.
342
What does it signify when the injured worker’s primary treating physician (PTP) states that the worker's lumbar spine has returned to pre-injury status?
It means that the lumbar spine injury has resolved.
343
When the injured worker’s primary treating physician (PTP) declares the injury permanent and stationary (P&S) and writes a permanent and stationary report (PR-4), does this imply that there is impairment or disability?
Yes, at least some permanent impairment/disability exits. Otherwise, the doctor could have discharged the worker as cured/ released from care.
344
Under what condition is a primary treating physician’s (PTP) permanent and stationary report (PR-4) classified as a medical-legal report?
When the claim is contested or disputed.
345
How is 'future medical care' defined?
Future medical benefits/ treatments are an injured worker’s right to receive ongoing medical treatment after a workers’ compensation injury claim has been settled/closed. The treatments should relieve or cure effects from the injury sustained at work.
346
When is an employer or defense party required to provide an interpreter for an injured worker who does not speak or understand English?
For treatment visits, medical-legal examinations, appeals board hearings, and depositions.
347
What are the penalties and fees if a California employer does not have workers' compensation insurance?
1 year imprisonment, fines up to $10,000, and state penalties up to $100,000.
348
How much is an employer liable if they do not have workers' compensation insurance and an employee is injured on the job?
The employer is responsible for all medical bills related to the injury. The injured worker can also file a civil lawsuit against the employer.
349
Who is responsible for paying disability and temporary disability benefits to the injured worker if the employer lacks workers' compensation insurance?
The Uninsured Employers’ Benefit Trust Fund (U.E.B.T.F.) pays benefits to injured workers if their employer was uninsured.
350
What does M.P.N. stand for, and who is responsible for selecting the doctors included in the M.P.N.?
Medical Provider Network (M.P.N.).Insurance companies choose which doctors are included within the MPN to treat injured workers. Each insurance company has its own MPN.
351
Who decides which doctors are listed on the M.P.N.?
Insurance companies choose which doctors are included within the MPN to treat injured workers. Each insurance company has its own MPN.
352
How much time does an employer have to grant access to a physician within the MPN after an injury is claimed?
24 hours.
353
If an injured worker being treated by a physician in the MPN requests a change of physician within the network, how quickly must this request be fulfilled?
Within 5 days of the request.
354
What occurs if an employer fails to provide an injured worker with a physician within the MPN within 30 days after the injury was claimed?
The injured worker may select any physician of their choosing.
355
What types of physicians are eligible to conduct Independent Medical Review (IMR) determinations regarding treatments for injured workers?
M.D.’s, D.O.’s, and D.P.M.’s.
356
How is the term 'secondary physician' defined?
This is any other physician besides the injured worker’s primary treating physician (PTP) who treats the injured worker.
357
Can medical records from a secondary treating physician be submitted as evidence at the Workers' Compensation Appeals Board (WCAB)?
No. Only reports from QMEs, AMEs, and PTPs are admissible. An exception does exist: if the PTP adopts the secondary physician’s report, then the report is admissible.
358
Under what circumstances can an employee change their pre-designated personal physician in the event of an industrial injury?
At any time.
359
What steps must an employee take to pre-designate their personal physician?
Pre-designation must be in writing, the personal physician must be an MD or DO, and the pre-designation must be provided prior to the industrial injury.
360
Who is accountable for providing the supplemental job displacement benefits voucher, also known as 'the voucher'?
The first doctor to make an injured worker Permanent and Stationary (P&S)/ determine that the injured worker has reached a point of maximal medical improvement.
361
Once an AME, QME, or Primary Treating Physician (PTP) concludes that a worker is Permanent and Stationary (P&S) or has reached maximal medical improvement, how many days does the physician have to submit the voucher?
60 days.
362
What is the value of the voucher for vocational rehabilitation benefits for injuries occurring on or after January 1, 2013?
A flat rate of $6,000.
363
What is the value of the vocational rehabilitation voucher for injuries that occurred before January 1, 2013?
A range from $1 to a maximum of $16,000.
364
What can the injured worker use the supplemental job displacement benefits voucher for?
Tools required for job training, licensing/certification/testing fees for a new job, schooling at a California public schools or other approved state providers, up to $1,000 for a computer, $500 in miscellaneous expenses, and up to $600 for a job placement agency or vocational counselor.
365
What can a QME do if they let their certification lapse by failing to pay re-certification fees, and an injured worker requests a re-evaluation?
The QME cannot do a face-to-face re-evaluation of this injured worker. However, the QME can issue a supplemental report (a supplemental report does not involve a face-to-face evaluation).
366
Is a physician allowed to bill for time spent reviewing previously reviewed medical records, their own reports and records, and for general deposition preparation?
Yes.
367
Is a physician permitted to bill for their travel time to attend a deposition?
Yes.
368
If no medical records are provided to the QME before or after the evaluation and the QME issues a report within the 30-day limit, but medical records are later received, what steps should the QME take?
Review the records and issue a supplemental report detailing the new findings and updating any opinions that the new information may have affected.
369
If no medical records are received by a QME before or after the evaluation, is the QME still required to issue a medical-legal report, and how long does the QME have to issue the report?
Yes. 30 days as per usual.
370
If no medical records are received by a QME before or after the evaluation, can the QME legally contact the injured worker's primary treating physician to obtain the records?
Yes.
371
When an injured worker does not speak English and is entitled to a certified California interpreter, what information must the QME document in the report?
The name and the certification number of the interpreter.
372
What does a -92 modifier represent when added to billing codes?
That the evaluation was performed by the primary treating physician (PTP).
373
What does a -93 modifier represent when added to billing codes?
That the evaluator had the help of a certified interpreter.
374
What does a -94 modifier represent when added to billing codes?
That the evaluation was an AME.
375
What does a -95 modifier represent when added to billing codes?
That the evaluation was an QME.
376
How is 'precipitation' defined?
Precipitation is when work exposure causes a previously asymptomatic condition or problem to manifest.
377
How is 'acceleration' defined?
Acceleration is when work exposure makes a previously asymptomatic condition or problem manifest sooner than without work. It also refers to work exposure rapidly worsening a condition.
378
Provide examples of situations in which an employer is not liable for a worker's injuries.
The employee was intoxicated or was illegally using controlled substance(s).The injury was intentionally self-inflicted.The employee committed suicide. Injuries from an altercation that the employee started. Injuries from a felony or crime.Injuries from recreational, social, and athletic activities, not related to usual work duties, unless the employer expected the employee to participate.Psychological injuries caused by being laid off/terminated/fired in good faith. These are discussed in Labor Code 3600 (LC 3600).
379
True or false: Each medical-legal report must include the following declaration, signed and dated with the county of signature, 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.'
True.
380
If a QME cannot complete an evaluation due to time constraints and asks the injured worker to return, how many days does the QME have to submit the report, and when does the time period start?
30 days, as per usual. The 30-day countdown starts at the first visit when the injured worker was seen.
381
Is a QME responsible for providing treatment or treatment advice to injured workers?
No. A QME evaluation is for assessment and evaluation only.
382
After ordering a diagnostic test that reveals a new diagnosis, what is the QME’s responsibility?
The QME must inform the parties of the new diagnosis and the QME can suggest other related medical assessments.
383
When a QME uses the AMA Guides and obtains an impairment rating with a decimal, what steps should the QME take?
Round to the nearest whole number.
384
True or false: Under California Workers' Compensation guidelines before 1/1/2005, 'constant' is defined as 90-100% of the time, 'frequent' as 75%, 'intermittent' as 50%, and 'occasional' as 25%.
True.
385
What is an 'agreed panel QME,' apart from a QME and an AME?
This is when a QME panel of 3 QME’s is generated and both the injured worker and the defense agree on one of the QMEs. In other words, there is no striking.
386
How is the term 'evidence-based' defined according to the DWC?
Based on medical journals included on the website www.pubmed.gov.
387
How are the 'three factors that demonstrate functional improvement' defined?
A clinically significant improvement in activities of daily living.A reduction in work restrictions as measured during the history and physical examination.A reduction in the dependency on continued medical treatment.
388
What constitutes good cause for the DWC medical director to grant permission for a second QME in a different specialty?
When the first QME says that an additional QME as needed in a different specialty.Upon the order of the Worker’s Compensation judge.The parties agree.
389
For psychological injuries that occurred on or after January 1, 2005 and are deemed permanent and stationary, what method is used to determine the extent of injury?
Global Assessment of Functioning score (GAF score).
390
What is used to assess impairment in a psychological injury claim?
Global Assessment of Function (GAF) scores.
391
What additional requirement must clinical psychologists fulfill to become psychology QMEs?
They must have at least 5 years of experience, after graduating, in treating psychological disorders.
392
If a QME is concerned that part of a report involving psychological injury may harm the injured worker's mental state, what two actions should the QME take?
Complete Form 120: “Voluntary direction for alternate service of medical-legal evaluation report on disputed injury to psyche (unrepresented employees only)” to have another doctor receive the report and explain it to the injured worker.Complete Form 121: “Declaration regarding protection of mental health record” to protect the disclosure of mental health records.
393
In psychology-related claims, what three elements must the injured worker generally prove?
That greater than 50% of the psychological injury was caused by work.The injured worker must have worked for the employer for over 6 months.The psychological injury must not be a consequence of a physical injury.
394
If a worker claims psychological injury after being threatened at gunpoint, what percentage of the psychological injury must the worker prove was work-related?
Because this is a violent act (a sudden and extraordinary event), 35% or greater is the threshold. In addition, the 6-month requirement does not apply.
395
If an employer terminates an employee for valid reasons and the employee files a claim, proving that 51% of their new psychological injury resulted from the termination, is the claim compensable?
No, because this was a “good faith personnel action.”
396
How long must a worker have been employed by an employer to be eligible to file a psychological injury claim?
6 months. The exception to this rule is if there was a sudden or extraordinary event.
397
What is the purpose of temporary disability indemnity (TDI) for a worker?
To substitute for the worker’s lost wages, in order to maintain a steady stream of income. This is also known as temporary disability benefits.
398
What are three situations in which an employer is no longer required to pay for temporary disability indemnity (TDI)?
The injured worker returns to work.The injured worker is deemed able to return to work.The injured worker’s medical condition achieves permanent and stationary status.
399
When an injured worker who typically lifts 100-pound bushels is restricted by their doctor to lifting no more than 10 pounds and the employer temporarily assigns the worker a desk job, what is this arrangement called?
Reasonable accommodation. This is also known as modified work.
400
What is it called when an injured worker's doctor restricts them from lifting more than 10 pounds and the employer has no available work, leaving the worker unable to work?
Temporary total disability (TTD).
401
For how long is an injured worker on temporary total disability entitled to receive temporary disability compensation (monetary payments) after January 1, 2005?
104 weeks (2 years).
402
What types of injuries qualify an injured worker for temporary disability benefits exceeding 104 weeks (240 weeks)?
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.
403
Under what circumstances can an injured worker who continues to work with reasonable accommodations also receive temporary disability compensation (monetary payments)?
If the modified work pays less than 85% of the injured worker’s usual salary.
404
When an injured worker feels better and returns to work with modified duties, do temporary disability payments cease?
Yes.
405
If an injured worker’s QME concludes that the worker's injuries will not improve and have reached maximal medical improvement/permanent and stationary status, do temporary disability payments stop?
Yes.
