QME Deck 2/2 Flashcards
Competency Exam
What factors are considered to determine a suitable impairment rating for a specific injury or illness?
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.
Why are physicians mandated by the Division of Workers’ Compensation (DWC) to use the AMA guidelines when evaluating impairments in injured workers?
To provide uniformity when calculating disability awards.
How is the term ‘strict rating’ defined in the context of impairment evaluation?
A strict rating refers to the textbook, standard and customary use of the AMA guides to determine an impairment rating.
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?
The method that gives the highest impairment rating is the most accurate rating.
In a Permanent and Stationary (P&S) report, what does the abbreviation WPI represent?
Whole person impairment. This is the same as permanent impairment.
What course of action should a QME take when an impairment is absent from the AMA guidelines?
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.”
What term is used when a QME compares an unlisted impairment to a listed one for the purpose of rating?
Rating by analogy.
Which landmark case provided the legal foundation for using ‘rating by analogy’?
Almaraz-Guzman.
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?
No, the rating by analogy can provide a different impairment rating.
What criteria must be fulfilled when applying rating by analogy or conducting an Almaraz-Guzman analysis?
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.
Is a rating by analogy or an Almaraz-Guzman analysis required for every case that is deemed Permanent and Stationary?
No.
How does the AMA Guides define anatomic loss?
Damage to an organ system or body structure.
What is the definition of functional loss according to the AMA Guides?
A change (decrease) in function for the organ or body system.
What process was followed to establish the impairment criteria outlined in the AMA Guides?
Through scientific evidence, consensus of chapter authors, and medical specialty society recommendations.
How many chapters of the AMA Guides are available for a QME to reference when rating an injured worker’s impairments?
As many as necessary to accurately rate permanent impairment.
BONUS: When employing rating by analogy or an Almaraz-Guzman analysis, what four steps is a QME expected to follow?
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.
What aspects must a QME assess and rate when assigning an impairment rating for an illness or injury, such as cancer?
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).
Is it appropriate for a QME to include subjective complaints when calculating impairment ratings?
Yes. The QME should collect a thorough history (subjective information) and perform a physical examination.
What is the process for a QME to convert an upper extremity impairment into a whole person impairment rating?
Multiple the upper extremity impairment by 0.6 (memory aid: hands are worth more than feet).
What method does a QME use to translate a lower extremity impairment into a whole person impairment?
Multiple the lower extremity impairment by 0.4 (memory aid: hands are worth more than feet).
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?
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%.
For a worker with well-managed diabetes who has reached maximum medical improvement, what is the process for calculating impairment?
This is a trick question. The QME should not assign impairment simply because of a diagnosis or a disease. There has to be impairment.
What was the purpose behind the development of the combined values chart in the AMA Guides?
So that multiple impairment calculations do not exceed 100% whole person impairment.
If a worker has impairments affecting the right hand, left knee, and cervical spine, how should the QME calculate the total whole person impairment?
The QME should use the Combine Values Chart on page 604 of the AMA Guides.
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.
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.
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.
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.
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.
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.
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.
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.
Does the ability to work fall under the category of Activities of Daily Living?
No.
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).
Before January 1, 2005, what standard or normal values were applied for assessing range of motion?
Packard Thurber’s “Estimated Average Normal” from 1960.
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
What is an alternative term used for apportionment?
“Causation of disability.”
What is a synonym for the term ‘causation of disability’?
Apportionment.
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.
What are the valid factors upon which apportionment can be based?
“Causation of permanent disability.”
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).
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.
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.
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.
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.
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.
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).
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.
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.
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.
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).
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.
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.”
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.”
Is a QME responsible for apportioning treatment?
No. Only permanent disability is apportioned.
Does a QME have the duty to apportion work restrictions?
No. Only permanent disability is apportioned.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.”
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.
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.”
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.
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.”
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.”
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.”
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.
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).
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).
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).
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.
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).
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).
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.
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.
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.
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.
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.).
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.).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Within the workers’ compensation system, is the act of proving or disproving a contested claim considered a valid ‘medical-legal expense’?
Yes.
Can a compensable injury result from both a specific event and cumulative trauma within the same case?
Yes.
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).
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).
Is it possible for future medical care to extend beyond two years?
Yes.
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.
What factors or conditions does a QME evaluate?
The QME rates permanent impairment. The QME provides permanent impairment ratings.
What else does a permanent impairment rating determine?
A determination regarding the extent of injury.
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.
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.
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.)
Is a QME with a specialty in acupuncture permitted to issue opinions on impairment ratings and permanent disability?
No.
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.
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.
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.).
What method is used to determine impairment ratings for injuries that occurred before January 1, 2005?
April 1997’s Permanent Disability Rating Schedule.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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).
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).
What is the intended purpose of prophylactic work restrictions?
To ensure that the injured worker does not sustain further injury.
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).
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).
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).
Under LC4662, how many days are payers given to settle a medical-legal expense?
60 days.
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.
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.
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.
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.
If an employee disagrees with substantial aspects of their primary treating physician’s disability evaluation, can the employee request a QME evaluation?
Yes.
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.
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.
Who is eligible to request a QME?
An employee (and their attorney, if any) or an employer (and their attorney, if any).
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.
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.
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.
Which organization in California is tasked with creating a panel of three QME physicians?
The Division of Workers’ Compensation (DWC) Medical Unit.
How many doctors are included in a QME panel?
Three.
How is the term ‘unrepresented injured worker’ defined?
An injured worker who is not represented by an attorney.
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.
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.
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).
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).
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.
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.
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.
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.
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.
