QME Study 1 Flashcards
1
Q
What is prohibited regarding advertising copy according to the regulations?
A
False or misleading advertising copy is prohibited.
2
Q
What does ‘QME’ stand for and how is it defined?
A
QME stands for Qualified Medical Evaluator as defined in Labor Code Section 139.2.
3
Q
What does ‘Advertising copy’ include according to the regulations?
A
Advertising copy includes any ‘public communication’ as defined in Business and Professions Code Section 651, which refers to any communication regarding the availability for professional employment of any physician, made by or on behalf of any physician to the general public or a substantial portion thereof.
4
Q
When is a document considered filed under these regulations?
A
Any document filed under these regulations shall be deemed filed on the date when it is received by the Administrative Director.
5
Q
What phrases are prohibited in firm names or trade names in advertising copy?
A
Firm names or trade names cannot contain the phrases ‘Qualified Medical Evaluator,’ ‘Qualified Medical Examiner,’ ‘Agreed Medical Evaluator,’ ‘Agreed Medical Examiner,’ ‘Independent Medical Examiner,’ ‘Independent Medical Evaluator’ or the designations ‘QME,’ ‘AME,’ or ‘IME.’
6
Q
What does advertising copy need to avoid regarding the credibility of medical-legal reports?
A
Advertising copy must not state or imply that a medical-legal report enjoys any special degree of credibility by any workers’ compensation judge or judges.
7
Q
What implication about a physician’s status is prohibited in advertising copy?
A
Advertising copy must not state or imply that any physician has an ongoing appointment, title, or professional status as an ‘Agreed Medical Examiner,’ ‘Agreed Medical Evaluator,’ ‘Independent Medical Examiner,’ ‘AME,’ or ‘IME.’
8
Q
When can the phrase ‘Qualified Medical Evaluator’ or the designation ‘QME’ be used in advertising?
A
The phrase ‘Qualified Medical Evaluator’ or the designation ‘QME’ can only be used to identify individual physicians who are currently certified as QMEs by the Administrative Director in accordance with Labor Code section 139.2.
9
Q
What type of recommendations are prohibited in advertising copy related to medical-legal examinations?
A
Advertising copy cannot advise or recommend the securing of any medical-legal examination or suggest that a tactical advantage may be secured by obtaining any medical-legal evaluation.
10
Q
What is prohibited in advertising copy regarding guarantees or predictions about medical outcomes?
A
Advertising copy cannot make or imply any guarantee, warranty, or prediction that creates a false or unjustified expectation of favorable results concerning the outcome of the employment of the physician.
11
Q
What must be included in any statement of Board Certification in advertising?
A
The name of the certifying board must be included in any statement of Board Certification.
12
Q
What is prohibited in advertising copy regarding a physician’s status in the California Workers’ Compensation system?
A
Any advertising copy which states or implies that the physician is currently an ‘Agreed Medical Examiner’ or ‘Independent Medical Examiner’.
13
Q
What information can a physician include in their advertising copy related to their practice?
A
A physician can include the name of each physician affiliated with their practice, the address, telephone number and business hours, areas of practice, individual physician’s appointment as a QME, Board Certification status, languages spoken, and a description of diagnostic or therapeutic facilities available.
14
Q
Can a physician who is not currently certified as a Qualified Medical Evaluator mention past certifications in advertising?
A
Yes, a physician may state any periods in the past during which they were certified as a Qualified Medical Evaluator in a curriculum vitae or descriptive text.
15
Q
What must a physician do before using advertising copy related to industrial injury or illness that contains material not specified in subsection (a)?
A
The physician must apply in writing to the Administrative Director for approval before using such material. Subsection (a) specifies the standard content allowed without prior approval.
16
Q
What information must be included in a complaint filed with the Medical Director?
A
The complaint must include the full name and address of the party filing the complaint and the full name and address of the physician against whom the complaint is made.
17
Q
What is required for all billings made by physicians in relation to medical services?
A
All billings must be made in compliance with the Official Medical Fee Schedule promulgated by the Administrative Director.
18
Q
What criteria does the Administrative Director use to approve advertising copy related to workers’ compensation?
A
The Administrative Director shall approve all requests that do not contain material which is false or likely to mislead the public with respect to workers’ compensation.
19
Q
What information must the complainant provide to assist the Administrative Director in identifying the physician who used the advertisement?
A
The complainant must provide a copy of the advertising copy or a description of the medium in which the advertising copy appeared, a detailed statement of the grounds on which the advertising copy is alleged to violate regulations, and any other relevant information.
20
Q
Can the Administrative Director or Medical Director initiate an investigation without a complaint?
A
Yes, they can act independently to initiate an investigation and issue a complaint if they have reason to believe there has been a violation of Business and Professions Code section 651 or the regulations.
21
Q
Where should complaints filed under Section 155 be submitted?
A
Complaints should be filed with the Medical Director at the Division of Workers’ Compensation, P.O. Box 71010, Attention: Medical Unit, Oakland, CA 94612.
22
Q
What is the time frame for a physician to file a copy of their advertising after receiving a notice of complaint?
A
The physician must file a copy of their advertising with the Medical Director within 15 working days of the date on which the notice was served.
23
Q
What is the time frame for the Medical Director to respond to a complaint after receiving the physician’s response?
A
The Medical Director shall respond within fifteen (15) working days.
24
Q
What are the possible actions the Administrative Director can take after receiving a complaint?
A
The Administrative Director can investigate the complaint, require additional time, refer the complaint to another agency, take no further action due to lack of jurisdiction, or take no further action because the allegations do not warrant further action.
25
Under what circumstances can the Administrative Director request a physician to provide advertising for review?
The Administrative Director may request a copy of any advertising used by the physician for review without receipt of a complaint, and such a request must be made in writing and personally served on the physician.
26
Can a physician present different grounds of defense after filing the initial answer to the complaint?
Yes, nothing in the answer precludes the physician from presenting further or different grounds of defense before the Administrative Director or appropriate licensing board.
27
What is the consequence for a non-QME physician who fails to deliver advertising material to the Administrative Director within fifteen working days?
The Administrative Director shall refer the matter to the physician's licensing board for appropriate proceedings.
28
What happens if a QME fails to deliver advertising material to the Administrative Director within fifteen working days?
The Administrative Director may infer that the advertising material is in violation of Business and Professions Code Section 651, which could lead to a suspension of the physician's appointment as a QME for six months followed by a probation period not exceeding one year.
29
What occurs if the Medical Director determines that a physician under investigation is not currently a QME?
The Medical Director will forward a copy of the preliminary determination, the complaint, and all supporting documentation to the appropriate physician's licensing board for further proceedings.
30
What penalties can a QME face for violating Business and Professions Code section 651?
A QME may have their status terminated, suspended, or placed on probation by the Administrative Director, with probation conditions deemed reasonable.
31
What actions does the Medical Director take if a QME's advertising copy is found to violate regulations?
The Medical Director will apply disciplinary and hearing procedures as set forth in sections 60 through 65 of Title 8 of the California Code of Regulations and forward a copy of the final decision to the physician's licensing board.
32
Is it lawful for a physician to refer a person for certain services if they have a financial interest in the entity receiving the referral?
No, it is unlawful for a physician to refer a person for specified services if the physician or their immediate family has a financial interest in the entity that receives the referral.
33
What factors does the Administrative Director consider when determining penalties for violations of Business and Professions Code section 651?
The factors include the seriousness of the misrepresentation, cooperation with the investigation, whether the violation was a single event or part of a pattern, prior discipline records, and records of contempt reprimands or adjudications.
34
How is 'financial interest' defined in this context?
A financial interest includes any type of ownership, interest, debt, loan, lease, compensation, remuneration, discount, rebate, refund, dividend, distribution, subsidy, or other form of direct or indirect payment between a licensee and a person or entity to whom the physician refers a person for a good or service.
35
Who is considered 'immediate family' of a physician?
Immediate family includes the spouse and children of the physician, the parents of the physician, and the spouses of the children of the physician.
36
What does 'diagnostic imaging' include?
Diagnostic imaging includes all X-ray, computed axial tomography, magnetic resonance imaging, nuclear medicine, positron emission tomography, mammography, and ultrasound goods and services.
37
What is defined as the 'office of a group practice'?
The office of a group practice is an office or offices in which two or more physicians are legally organized as a partnership, professional corporation, or not-for-profit corporation, providing a full range of services through shared office space, facilities, equipment, and personnel.
38
What constitutes a 'physician's office'?
A physician's office is either an office of a physician in solo practice or an office where services or goods are personally provided by the physician or by employees or independent contractors in accordance with the law.
39
What is the definition of 'outpatient surgery' according to the provided text?
Outpatient surgery includes any procedure performed on an outpatient basis in operating rooms, ambulatory surgery rooms, endoscopy units, cardiac catheterization laboratories, or other sections of a freestanding ambulatory surgery clinic, as well as the ambulatory surgery itself.
40
What are the consequences of violating the referral regulations outlined in the text?
Violations may result in misdemeanor charges, disciplinary action by the appropriate licensing board, and civil penalties of up to five thousand dollars ($5,000) for each offense, enforceable by the Insurance Commissioner, Attorney General, or a district attorney.
41
What constitutes 'pharmacy goods' as defined in the text?
'Pharmacy goods' means any dangerous drug or dangerous device as defined by Section 4022 of the Business and Professions Code, any medical food as defined by Section 109971 of the Health and Safety Code, and any over-the-counter drug classified by the federal Food and Drug Administration, except those sold at commercially reasonable rates in physical retail outlets commonly accessed by the public.
42
What must a physician disclose when referring to an organization in which they have a financial interest?
A physician must disclose their financial interest to the patient or, if the patient is a minor, to the patient's parents or legal guardian in writing at the time of the referral.
43
Is it lawful for a licensee to enter into a cross-referral arrangement?
No, it is unlawful for a licensee to enter into an arrangement or scheme, such as a cross-referral arrangement, that has a principal purpose of ensuring referrals to a particular entity that would violate the section if directly referred.
44
What are the requirements for a lease of space or equipment between a physician and the recipient of a referral?
The lease must be written, have commercially reasonable terms, have a fixed periodic rent payment, have a term of one year or more, and the lease payments must not be affected by referrals or the volume of services provided.
45
Under what conditions can a physician refer a patient for a service otherwise prohibited?
A physician may refer a patient if there is no alternative provider of the service within either 25 miles or 40 minutes traveling time via the shortest route on a paved road.
46
What must a physician disclose to a patient when referring them to an organization in which the physician has a financial interest?
The physician must disclose the financial interest to the patient or the patient's parents or legal guardian in writing at the time of referral.
47
What are the conditions under which a loan between a physician and the recipient of a referral is permissible?
The loan must have commercially reasonable terms, bear interest at the prime rate or higher, be adequately secured, and the loan terms must not be affected by referrals or the volume of services provided.
48
What is the maximum fine for each violation under the discussed regulations?
The maximum fine for each violation is fifteen thousand dollars ($15,000).
49
Who must receive written notice disclosing the existence of a personal services arrangement?
The injured worker referred by a licensee or an immediate family member of the licensee and the injured worker's employer, if self-insured.
50
What is the minimum total gross assets a corporation must have to be subject to specific regulations regarding physician referrals?
A corporation must have total gross assets exceeding one hundred million dollars ($100,000,000).
51
What are the requirements for a personal services arrangement between a physician and the recipient of a referral?
The arrangement must be in writing and signed by the parties, specify all services to be provided, ensure that the aggregate services do not exceed what is reasonable and necessary for legitimate business purposes, and provide written notice disclosing the arrangement to the injured worker and their employer.
52
Under what condition can compensation for medical services be determined?
Compensation for medical services shall be subject to the official medical fee schedule or any contract authorized by Section 5307.11.
53
What type of counseling or promotion is prohibited under the arrangement?
The arrangement must not involve counseling or promotion of any business arrangement or activity that violates state or federal law.
54
What is the minimum term for the arrangement mentioned in the text?
The term of the arrangement is for at least one year.
55
Can a physician refer a person to a health facility if they receive compensation for the referral?
No, the recipient of the referral must not compensate the physician for the patient referral.
56
What must the compensation paid over the term of the arrangement not exceed?
The compensation must not exceed fair market value.
57
Can a physician employed by a university refer a patient to a facility owned by the university?
Yes, provided that the facility or university does not compensate the referring physician for the patient referral.
58
What is the prohibition of Section 139.3 regarding referrals?
The prohibition shall not apply to any service for a specific patient performed within a physician's office or the office of a group practice.
59
What must a physician obtain for nonemergency outpatient diagnostic imaging services with equipment priced at $400,000 or more?
The referring physician shall obtain a service preauthorization from the insurer or self-insured employer.
60
What is required if a physician receives oral authorization for a service?
Any oral authorization shall be memorialized in writing within five business days.
61
Under what condition can a physician in a group practice refer a person to a multispecialty clinic?
The prohibition of Section 139.3 shall not apply where the physician is in a group practice and refers a person for services specified in Section 139.3.
62
When does the prohibition of Section 139.3 not apply to a physician's financial interest in a retailer of prescription drugs?
The prohibition does not apply provided that the majority of the physician's practice does not relate to occupational medicine and the physician receives no remuneration from the retailer to market or solicit occupational injury or disease patients.
63
What is required for an outpatient surgical center regarding service preauthorization?
The referring physician must obtain a service preauthorization from the insurer or self-insured employer after disclosure of the financial relationship.
64
Under what condition does the prohibition of Section 139.3 not apply to a facility providing health care services?
The prohibition of Section 139.3 shall not apply when used to provide health care services to an enrollee of a health care service plan licensed pursuant to the Knox-Keene Health Care Service Plan Act of 1975.
65
What must be done with any oral authorization obtained for service preauthorization?
Any oral authorization shall be memorialized in writing within five business days.
66
What is required for a physician to obtain service preauthorization when exceeding routine screening battery protocols?
The referring physician shall obtain a service preauthorization from the insurer or self-insured employer.
67
To whom does the requirement for preauthorization not apply according to the specified sections?
The requirement for preauthorization shall not apply to a patient for whom the physician or group accepts payment on a capitated risk basis.
68
When must specified financial interests be disclosed on QME SFI Form 124?
When applying for appointment on QME Form 100, at the time of paying the annual fee on QME Form 103, or when applying for reappointment on QME Form 104.
69
What constitutes 'Specified Financial Interests' for a Qualified Medical Evaluator?
Being a general partner or limited partner in, or having an interest of five percent or more in, or receiving or being legally entitled to receive a share of five percent or more of the profits from any medical practice or entity that provides treatment or medical evaluation in the California workers' compensation system.
70
What happens if two or more QMEs assigned to a panel share specified financial interests?
Any party may request a replacement QME, and if three QMEs share specified financial interests, two of them shall be replaced.
71
What are the consequences of failing to complete and file a QME SFI Form 124?
It shall be grounds for disciplinary action pursuant to section 60 of Title 8 of the California Code of Regulations.
72
What is the purpose of the QME SFI Form 124?
It is completed and filed as an attachment to QME Form 100, 103, or 104 by the physician or QME with the Medical Director of the Division of Workers' Compensation.
73
What must every physician seeking appointment or reappointment as a Qualified Medical Evaluator disclose?
Specified financial interests as defined in section 1 (dd) and 29(b) of Title 8 of the California Code of Regulations.
74
How does the Administrative Director use the information provided by physicians regarding specified financial interests?
To avoid assigning QMEs who share specified financial interests to the same QME panel.
75
What must an evaluator selected from a QME panel advise an injured worker prior to or at the time of the actual evaluation?
The evaluator must advise the injured worker that they are entitled to ask questions about the evaluation process and that they may discontinue the evaluation based on good cause.
76
What constitutes 'good cause' for an injured worker to discontinue the evaluation?
Good cause includes discriminatory conduct by the evaluator, abusive or rude behavior, and instances where the evaluator requests unnecessary exams or procedures.
77
What must a QME disclose if required as a condition of probation?
The QME must disclose his/her probationary status and is entitled to explain any circumstances surrounding the probation.
78
What are the ethical requirements for QMEs regarding their office environment?
All QMEs must maintain a clean, professional physician's office with functioning medical instruments and equipment appropriate for conducting evaluations.
79
Are QMEs allowed to refuse scheduling appointments based on the representation status of the injured worker?
No, a QME shall not refuse to schedule an appointment with an injured worker solely because the worker is not represented by an attorney.
80
What rights does an injured worker have if they decline to ask questions during the evaluation?
The injured worker shall have no right to object to the QME comprehensive medical-legal evaluation based on a violation of this section.
81
What happens if an injured worker declines to proceed with the evaluation?
The termination shall be considered by the Administrative Director to have occurred for good cause.
82
What is prohibited for a medical evaluator in terms of providing treatment to an injured worker?
A medical evaluator must refrain from treating or soliciting to provide medical treatment, medical supplies, or medical devices to the injured worker.
83
How many times can a medical evaluator unilaterally reschedule a panel QME examination in the same case?
A medical evaluator should refrain from unilaterally rescheduling a panel QME examination more than two times in the same case.
84
How should a medical evaluator communicate with an injured worker?
A medical evaluator should communicate with the injured worker in a respectful, courteous, and professional manner.
85
What must a medical evaluator provide if they cancel a QME examination?
If a medical evaluator cancels a QME examination, they must provide a new examination date within thirty calendar days of the date of cancellation.
86
What should a medical evaluator refrain from doing regarding unnecessary exams or procedures for an injured worker?
A medical evaluator should not request the employee to submit to an unnecessary exam or procedure.
87
What regulation must a medical evaluator refrain from violating according to the California Code of Regulations?
A medical evaluator must refrain from violating section 41.5 of Title 8 of the California Code of Regulations.
88
What is the minimum notice period required for cancelling a QME examination without good cause?
A medical evaluator must refrain from cancelling a QME examination less than six business days from the date the exam is scheduled without good cause.
89
What must the report generated by QMEs include?
The report must list and summarize all medical and non-medical records reviewed as part of the evaluation.
90
What factors must QMEs consider when rendering expert opinions?
QMEs must render opinions without regard to an injured worker's race, sex, national origin, religion, or sexual preference.
91
What qualifications must QMEs have to render expert opinions?
QMEs must have adequate qualifications, education, and training on the issues they are evaluating.
92
What is required of QMEs before generating a written report?
QMEs must review all available relevant medical and non-medical records and/or facts necessary for an accurate and objective assessment of the contested medical issues.
93
What is prohibited for evaluators selected from a QME panel according to Labor Code section 4062.3?
Evaluators shall not engage in ex parte communication.
94
On what basis should QMEs render expert opinions or conclusions?
QMEs should render expert opinions or conclusions based on facts, their training, and specialty-based knowledge, without bias for or against any party.
95
What must all QMEs refuse regarding compensation?
All QMEs must refuse any compensation from any source contingent upon writing an opinion that could be construed as unfavorable to a party to the case.
96
What should be included in the portions of the report discussing medical issues?
The report should include discussions of medical issues, medical research used as the basis for medical determinations, and medical conclusions made by the evaluator.
97
Who should receive the report upon service?
The report should be served at the same time on the employee, the claims administrator, or if none, the employer, and on each of their attorneys, respectively.
98
How should a consultation report from a different specialty be handled?
The consultation report shall be incorporated by reference into the final report and appended to the referring QME's report.
99
What can an injured worker do if they are not seen by the evaluator within one hour?
They may terminate the exam and request a replacement evaluator from the Administrative Director.
100
What is the maximum wait time an injured worker should experience before being seen for an evaluation?
An injured worker should not wait more than one hour at the evaluator's office prior to being seen.
101
What must an evaluator do if they terminate the evaluation process?
They must state under penalty of perjury the facts supporting the termination.
102
What happens if an injured worker terminates the examination process based on an alleged violation and the Appeals Board finds no good cause?
The cost of the evaluation shall be deducted from the injured worker's award.
103
What must all aspects of comprehensive medical-legal evaluations be directly related to?
Contested medical issues as presented by any party or addressed in the reports of treating physician(s).
104
What is the evaluator's obligation if the injured worker is intoxicated or under the influence of impairing medication?
The evaluator is not required to undertake or continue the evaluation.
105
Under what circumstances can an evaluator terminate a comprehensive medical-legal evaluation?
If the injured worker uses abusive language or attempts to disrupt the operation of the evaluator's office.
106
What is prohibited for an evaluator under §41.5 regarding compensation?
An evaluator shall not request or accept any compensation or other thing of value from any source that could create a conflict with their duties as an evaluator.
107
What constitutes a conflict with the duties of an evaluator according to Labor Code section 139.2(o)?
A conflict with the duties of an evaluator means having a disqualifying conflict of interest with certain persons or entities and failing to disclose the fact of the conflict.
108
Who are the persons or entities that can create a disqualifying conflict of interest for an evaluator?
The injured worker or their attorney, the employer or the employer's attorney, and the claims adjuster, insurer, or third party administrator or their attorney.
109
What is a 'Disqualifying Conflict of Interest' in the context of medical evaluations?
A 'Disqualifying Conflict of Interest' means the evaluator has any familial relationship or interests with a person or entity involved in the case.
110
When can other purveyors of medical goods or services be involved in a case?
Other purveyors can be involved only if the medical necessity for using such goods or services is in dispute in the case.
111
Who can be considered a primary treating physician in a disputed case?
Any primary treating physician or secondary physician for the employee, if the treatment provided by that physician is disputed in the case.
112
Under what condition can a surgical center be involved in a disputed case?
The surgical center can be involved only if the need for surgery is disputed in the case.
113
When can a utilization review physician reviewer be involved in a case?
The utilization review physician reviewer or expert reviewer can be involved only if their opinion is disputed in the case.
114
What constitutes a significant disqualifying financial interest in the context of workers' compensation matters?
A significant disqualifying financial interest includes employment or a promise of employment, an interest of five percent or more in the fair market value of any business entity involved in workers' compensation, five percent or more of the evaluator's income from direct referrals or contracts with certain entities, and any financial interest that precludes referral as defined in Labor Code section 139.3.
115
What information must be included in the written notice of a disqualifying conflict of interest?
The notice must include disclosure of the conflict, the person or entity with whom the conflict arises, and the category of conflict, such as familial, significant financial, or other ethical conflict.
116
What should an evaluator do if they have a disqualifying conflict of interest?
The evaluator should send written notification to the injured worker and the claims administrator, or employer, within five business days of becoming aware of the conflict.
117
What actions must an Agreed Medical Evaluator or Qualified Medical Evaluator take if they decline to perform an evaluation due to a conflict of interest?
They must notify the relevant parties in writing about the disqualifying conflict of interest.
118
What does a professional affiliation mean in the context of medical evaluations?
It means the evaluator performs services in the same medical group or other business entity comprised of medical evaluators who specialize in workers' compensation medical-legal evaluations.
119
What is a financial interest as defined under the Physician Ownership and Referral Act of 1993 (PORA)?
A financial interest that would preclude referral by the evaluator to a person or entity as set out in Business and Professions Code sections 650.01 and 650.02.
120
What must an evaluator do when they become aware of a potential disqualifying conflict of interest?
The evaluator must notify the selected evaluator in writing at the earliest opportunity and no later than within five (5) business days of becoming aware of the potential conflict.
121
What should the notice of potential conflict include?
The notice shall include the person with whom the alleged conflict exists and the nature of the conflict.
122
What is required when an injured worker is not represented by an attorney and a conflict arises?
The evaluator shall fax a copy of the notice of conflict to the Medical Unit of the Division of Workers' Compensation at the same time it is sent to the parties.
123
What disputes may arise regarding an evaluator's conflict of interest?
Disputes may arise over whether the conflict affects the integrity and impartiality of the evaluator with respect to an evaluation report or supplemental report, and over the waiver of the evaluator's conflict.
124
What is the attorney's responsibility regarding the signed waiver document in a represented case?
It is the duty of the attorney to serve a copy of the signed document on the party-client.
125
What is required from each party if the injured worker is represented by an attorney and there is a conflict of interest with the evaluator?
Each party shall notify the evaluator and the opposing party in writing of their decision to either waive the conflict or object to the evaluator based on the conflict.
126
What conditions must be met for a waiver of conflict of interest to be valid in a represented case?
The general nature of the conflict must be disclosed in writing, and both parties must sign a statement indicating they understand the conflict and wish to waive the opportunity to obtain another evaluator.
127
What disciplinary action can a Qualified Medical Evaluator face for violating the gift acceptance regulations?
A Qualified Medical Evaluator who violates any portion of the gift acceptance regulations shall be subject to disciplinary action pursuant to section 60 et seq of these regulations.
128
Who has the burden of proof if a person claims that a payment or benefit is not a gift?
The person claiming that it is not a gift has the burden of proving that the consideration received is of equal or greater value.
129
What is the maximum total fair market value of gifts that a physician can accept from a single source in a twelve-month period while acting as an Agreed Medical Evaluator or Qualified Medical Evaluator?
360
130
What constitutes a 'Gift' according to the regulations for medical evaluators?
A 'Gift' means any payment for which consideration of equal or greater value is not received, including rebates or discounts unless made in the regular course of business to the public.
131
What form is required to be completed when serving medical-legal evaluation reports?
QME Form 122 (AME or QME Declaration of Service of Medical-Legal Report Form) must be completed and attached to the report.
132
What must an evaluator do when serving comprehensive medical-legal evaluation reports for an injured worker represented by an attorney?
The evaluator must serve each comprehensive medical-legal evaluation report, follow-up comprehensive medical-legal evaluation report, and supplemental evaluation report on the injured worker, their attorney, and the claims administrator or employer by completing QME Form 122 and attaching it to the report.
133
What documents must be served when addressing findings related to permanent impairment or disability for an unrepresented injured worker?
The evaluator must serve the evaluation report with a separator sheet, QME Form 111 with a separator sheet, DWC-AD Form 100 with a separator sheet, and DWC-AD Form 101 with a separator sheet.
134
What is required to be served simultaneously on the local DEU office when serving a medical evaluation report?
The documents listed in Title 8, California Code of Regulations section 10160(d)(4) must be served simultaneously on the local DEU office, claims administrator, or employer, and on the unrepresented employee.
135
Can a physician who is not a QME perform a follow-up evaluation on an unrepresented injured worker?
No, a physician who is not a QME or is no longer a QME may not perform a follow-up evaluation on an unrepresented injured worker.
136
Under what conditions can a Qualified Medical Evaluator issue a supplemental report after finding permanent impairment or disability?
A QME shall not issue a supplemental report on those issues until after the Disability Evaluation Unit has issued an initial summary rating report, unless directed otherwise.
137
What should an evaluator do if an unrepresented employee's condition is not permanent and stationary?
The parties shall request any further evaluation from the same QME if the QME is currently active and available
138
What is the employer's responsibility regarding the designated physician for discussing the evaluation report?
The employer will be responsible for payment for one office visit with the designated physician for the purpose of reviewing and discussing the evaluation report with the injured worker.
139
What should the evaluator advise the injured worker regarding the service of the comprehensive medical-legal report in claims of injury to the psyche?
The evaluator should advise the injured worker that the report may be served either directly on the injured worker or on a physician designated in writing by the injured worker prior to leaving the evaluator's office.
140
What form must be completed and attached to the evaluation report in the injured worker's medical or medical-legal file?
QME Form 121 (Declaration Regarding Protection of Mental Health Record) must be completed and attached to the evaluation report.
141
Who is permitted to inspect and copy the mental health records according to Health and Safety Code section 123115(b)?
Only a licensed physician or another health care provider as defined in Health and Safety Code section 123105(a) is permitted to inspect and copy the mental health records.
142
What additional forms must be served along with the report if it addresses permanent impairment and the injured worker is not represented by an attorney?
The report must be served along with QME Form 111 (QME's Findings Summary Form), DWC-AD form 100 (Employee's Disability Questionnaire), DWC-AD form 101 (Request for Summary Rating Determination), and the document cover sheet DWC-CA form 10232.1.
143
What should the evaluator do if the injured worker prefers to have the evaluation report served on a designated physician?
The evaluator should provide QME Form 120 (Voluntary Directive for Alternate Service of Medical-Legal Report) to the injured worker and request them to complete the form before leaving the evaluator's office.
144
What is the definition of a 'mental health record' in the context of workers' compensation claims?
A 'mental health record' refers to a medical treatment or evaluation record created by or reviewed by a licensed physician during the treatment or evaluation of an injured worker in a workers' compensation claim, including treatment records and comprehensive medical-legal reports.
145
Can the physician designated by the injured worker be limited to the primary treating physician?
No, the physician designated by the injured worker is not limited to the primary treating physician in the disputed workers' compensation claim.
146
Who must receive copies of the medical-legal report when served with QME Form 120?
The designated physician, the claims administrator or employer, and the injured worker's attorney must receive copies of the medical-legal report.
147
What is the purpose of QME Form 122?
QME Form 122 is used to complete the declaration of service of the medical-legal report.
148
Who should receive the worker's copy of the report under Health and Safety Code § 123115(b)?
The worker's copy of the report shall be served only on the injured worker's attorney, if represented, or if not represented, on the injured worker's primary treating physician.
149
What is defined as 'electronic service' in the context of medical-legal reports?
'Electronic service' means service of the medical-legal report and all documents required by section 36, on a party or other person, by either electronic transmission or electronic notification.
150
What does 'electronic transmission' refer to?
'Electronic transmission' refers to the transmission of a document by electronic means to the electronic service address at or through which a party or other person has authorized electronic service.
151
What can replace the mandatory form 122 for electronic service of medical-legal reports?
An Affidavit of Proof of Electronic Service can replace the mandatory form 122.
152
What happens to the notice period after the electronic service of a document?
Any period of notice and any right or duty to act or make any response shall be extended by two business days.
153
If the request for factual correction is filed by the claims administrator or both parties, how long is the review period extended?
Fifteen (15) days after the service of the request for correction.
154
How long does an injured worker have to respond to a request for factual correction if the claims administrator serves the request?
Five (5) days after the service of the request for factual correction.
155
Who must be served when a request for factual correction is made?
The panel Qualified Medical Evaluator, the party who did not file the request, and the Disability Evaluation Unit office.
156
What is the time frame for an unrepresented employee or claims administrator to request a factual correction of a comprehensive medical-legal report from a panel QME?
30 days from the receipt of the comprehensive medical-legal report.
157
What is the time frame for a panel QME to review a request for factual correction if filed by the injured worker?
Ten (10) days after service of the request.
158
What must the panel QME file at the end of the review period for a request for factual correction?
A supplemental report with the DEU office indicating whether factual corrections are necessary and if they change the opinions stated in the original report.
159
What happens if an evaluator fails to prepare and serve the medical evaluation report within thirty days without obtaining an extension?
The employee or the employer may request a QME replacement.
160
What is the maximum time frame for an initial or follow-up comprehensive medical-legal evaluation report to be submitted after the QME has seen the employee?
The maximum time frame is thirty (30) days.
161
What is the maximum extension period granted for good cause?
An extension of fifteen (15) days.
162
What forms must be signed to waive the right to a new evaluation if the original evaluation is not completed on time?
QME Form 113 or QME Form 116.
163
What form must an evaluator use to request an extension of time for completing a medical evaluation report?
Form 112 (QME/AME Time Frame Extension Request).
164
Under what circumstances can an evaluator be granted an extension of up to thirty days?
When the evaluator has not received test results or the report of a consulting physician necessary to address all disputed medical issues in time to meet the initial 30-day deadline.
165
What form does the Medical Director send if a report has not been completed within the required time and no extension was requested?
The Medical Director shall send the parties a Notice of Late QME/AME Report - No Extension Requested (QME Form 116).
166
What must the Medical Director do upon receiving a request for an extension?
The Medical Director shall notify the requesting evaluator and the parties of the decision on the extension request by completing the box at the bottom of QME Form 112.
167
What constitutes 'good cause' for requesting an extension?
Good cause includes medical emergencies of the evaluator or their family, death in the evaluator's family, and natural disasters or community catastrophes that interrupt the evaluator's office operations.
168
What happens if a request for an extension of time is denied?
The Medical Director shall send the parties QME Form 113 to state whether they wish to request a new evaluator or accept the late report of the original evaluator.
169
What is the timeframe for an evaluator to notify the Medical Director and other parties of a request for an extension using QME Form 112?
Not later than 5 days before the initial 30-day period to complete and serve the report expires.
170
Can extensions be granted due to the lack of relevant medical information or records?
No, extensions shall not be granted because relevant medical information/records have not been received.
171
What is the maximum time frame for supplemental reports from a physician after a request?
The maximum time frame for supplemental reports is no more than sixty (60) days from the date of a written or electronically transmitted request.
172
What may constitute grounds for denial of a QME's request for reappointment?
Failure to comply with the time frame for supplemental reports may constitute grounds for denial of the QME's request for reappointment.
173
What must accompany a request for a supplemental report?
The request for a supplemental report must be accompanied by any new medical records that were unavailable to the evaluator at the time of the original evaluation.
174
How long must QMEs retain comprehensive medical-legal reports?
QMEs must retain a copy of all comprehensive medical-legal reports for a period of five years from the date of each evaluation report.
175
What happens if an evaluator fails to submit evaluations upon request by the Medical Director?
Failure to submit evaluations upon request by the Medical Director may constitute grounds for disciplinary action.
176
What is required of a QME when returning original medical records upon request?
A QME is required to return original radiological films, imaging studies, and original medical records to the person who supplied the original records or to the injured worker upon written request.
177
What rights does an injured employee have regarding interpreter services during a medical examination?
An injured employee is entitled to the services of a qualified interpreter if they cannot effectively communicate in English, and the employer or insurance carrier must pay for these services upon request.
178
What are the requirements for an employer to pay for interpreter services?
The employer must pay for interpreter services unless the interpreter is provisionally certified and the employer has not consented to the selection of the interpreter or the injured worker requires interpreting in a language not designated by law.
179
What conditions define a contested claim?
A contested claim exists when the employer rejects liability for a claimed benefit, fails to accept liability after a reasonable period, or fails to respond to a demand for payment after the statutory time period.
180
What constitutes a medical-legal expense?
A medical-legal expense includes costs incurred for X-rays, laboratory fees, diagnostic tests, medical reports, medical records, medical testimony, and interpreter’s fees for proving or disproving a contested claim.
181
Under what circumstances do costs of medical evaluations and interpreters qualify as medical-legal expenses?
Costs qualify as medical-legal expenses only if the medical report can prove or disprove a disputed medical fact essential to the adjudication of the employee’s claim for benefits.
182
What is required of a physician if the initial outline of a patient's history is not done by them?
The physician shall review the excerpts and the entire outline and make additional inquiries and examinations as necessary to identify and determine the relevant medical issues.
183
What are the responsibilities of a nurse in the preparation of a medical evaluation report for an injured employee?
A nurse shall examine the injured employee, take a complete history, review and summarize prior medical records, and compose and draft the conclusions of the report.
184
What should a report explain if the evaluation performed was not in compliance with established guidelines?
The report shall explain, in detail, any variance from the guidelines and the reasons for such variance.
185
What charges may be included in the costs for producing a medical evaluation report?
Charges may include direct charges for the physician's professional services, reasonable costs of laboratory examinations, diagnostic studies, other medical tests, and reasonable clerical expenses necessary to produce the report.
186
What information must be disclosed in a medical evaluation report?
The report must disclose the date and location of the evaluation, the identity of the physician who performed the evaluation, compliance with established guidelines, and the name and qualifications of each person who performed services related to the report.
187
What happens if a report fails to comply with the requirements of the section?
The report becomes inadmissible as evidence and eliminates any liability for payment of medical-legal expenses incurred in connection with the report.
188
What must be specified when billing for medical-legal evaluations performed by others?
The amount paid or to be paid to those persons for the evaluations, procedures, or services must be specified.
189
What is the civil penalty for a physician who knowingly fails to comply with the requirements of this section?
The civil penalty can be up to one thousand dollars ($1,000) for each violation.
190
What must a report contain regarding the declaration by the physician signing it?
It must contain a declaration under penalty of perjury stating that the information is true and correct to the best of the physician's knowledge and belief.
191
What actions can be taken against a physician assessed a civil penalty under this section?
The physician may be terminated, suspended, or placed on probation as a qualified medical evaluator.
192
Who is excluded from the QME panel selection process?
Any QME who has informed the Medical Director that he or she is unavailable pursuant to section 33 of Title 8 of the California Code of Regulations.
193
Can a physician who has treated an employee perform a QME evaluation on that employee?
No, any physician who has served as a primary or secondary treating physician for the disputed injury shall not perform a QME evaluation on that employee.
194
Who resolves disputes regarding the validity of panel requests in represented cases?
A Workers' Compensation Administrative Law Judge.
195
How are QME panels selected?
Panels are selected randomly from the appropriate specialty identified by the party who holds the legal right to designate the specialty, considering the proximity of the QME's medical office to the employee's residence.
196
What is required to issue a QME panel in a selected specialty?
There must be at least five active QMEs in the specialty at the time the panel selection is requested.
197
What happens if a party cannot obtain an appointment with a QME within ninety days of the appointment request?
The party may waive the right to a replacement and accept an appointment no more than one-hundred-twenty days after the initial request.
198
What are the conditions under which a replacement QME can be selected?
A replacement QME can be selected if a QME does not practice in the requested specialty, cannot schedule an examination within the required time, the injured worker's address has changed, or if a physician on the panel is in the same group practice as another QME on the panel.
199
What provisions apply to requests for Comprehensive Medical-Legal Evaluations and Follow Up Evaluations?
Requests for Comprehensive Medical-Legal Evaluations and Follow Up Evaluations must comply with the specific guidelines set forth for these evaluations, ensuring timely and appropriate handling by a QME.
200
Under what circumstances can a replacement QME be selected at random by the Medical Director?
A replacement QME can be selected if a QME does not practice in the requested specialty, cannot schedule an examination within the required timeframes, the injured worker has changed their residence, or if a physician on the panel is in the same group practice as another QME on the panel.
201
Under what circumstances can a party report the unavailability of a QME?
When the selected QME cannot schedule the evaluation within one-hundred-twenty days of the initial request for an appointment.
202
What is the time limit for scheduling an evaluation with a selected QME after waiving the right to a replacement?
The evaluation must be scheduled no more than one-hundred-twenty days after the date of the party's initial request for an appointment.
203
What can either party do when a selected QME is unavailable to schedule the evaluation within one-hundred-twenty days?
Either party may report the unavailability of the QME, and the Medical Director shall issue a replacement upon request.
204
What must be submitted with a panel replacement request for it to be considered for the employee's convenience?
A written agreement between the claims administrator or employer and the employee must be submitted, indicating that a new panel may be issued in the geographic area of the employee's workplace.
205
What documentation must be submitted for the Medical Director to determine the appropriateness of a replacement QME?
A written request along with a copy of the Doctor's First Report of Occupational Injury or Illness and the most recent DWC Form PR-2 or a narrative report filed in lieu of the PR-2.
206
Under what circumstance will an evaluator not be replaced for violating section 34?
The evaluator will not be replaced if the request for a replacement is made more than fifteen calendar days from when the party became aware of the violation or the date the report was served by the evaluator.
207
What documentation is required for the Medical Director to determine the appropriateness of a specialty for a disputed medical issue?
The Medical Director requires a copy of the Doctor's First Report of Occupational Injury or Illness and the most recent DWC Form PR-2 or a narrative report filed in lieu of the PR-2.
208
What are the conditions under which a QME may be considered unavailable according to section 33?
The QME is unavailable if they are no longer available, if the evaluator who previously reported in the case is unavailable, or if a QME on the panel has been the employee's primary or secondary treating physician.
209
What constitutes 'good cause' for requesting a replacement QME?
'Good cause' is defined as a documented medical or psychological impairment related to the injury.
210
What constitutes 'good cause' for a replacement QME according to the Medical Director?
Good cause is defined as a documented medical or psychological impairment.
211
What are the conditions under which a QME may be deemed unavailable according to section 33?
A QME may be deemed unavailable if the evaluator who previously reported in the case is no longer available, if a QME named on the panel has been the employee's primary or secondary physician, or if the Medical Director finds good cause for a replacement.
212
What agreement is required for a new panel to be issued for the employee's convenience?
The claims administrator or employer and the employee must agree in writing that a new panel may be issued in the geographic area of the employee's workplace.
213
What happens if the QME panel list was issued more than 24 months prior to the request for a replacement?
None of the QMEs on the panel list can have examined the injured worker.
214
If two QME names have been struck from a panel in a represented case, what is the rule for including QMEs in the replacement panel?
None of the QMEs whose names appeared on the earlier QME panel shall be included in the replacement QME panel.
215
What must a selected medical evaluator provide if they refuse to conduct a complete medical evaluation?
They must provide a written statement explaining why they believe they are not medically qualified or competent to address one or more issues in dispute.
216
What must a party requesting a replacement QME on the grounds of lateness attach to their request?
A copy of the party's objection to the untimely report.
217
What should a party requesting a replacement QME do if the evaluator failed to meet the deadlines specified in Labor Code section 4062.5?
The party requesting a replacement must attach a copy of their objection to the untimely report to the request for a replacement.
218
What constitutes a disqualifying conflict of interest for a QME?
A disqualifying conflict of interest occurs when a QME has a financial interest in the outcome of the evaluation, a personal relationship with any party involved, or any other situation that could compromise their impartiality.
219
Under what circumstances can the Administrative Director issue an order for an additional QME evaluation?
The Administrative Director can issue an order when there is a need for further evaluation due to complex medical issues that cannot be addressed by the existing QME panel, as outlined in section 10164(c) of Title 8 of the California Code of Regulations.
220
What occurs to the time limits for selecting a QME when a valid request for a replacement is made?
The time limit for an unrepresented employee to select a QME and schedule an appointment is tolled until the replacement QME name or panel is issued.
221
What happens to the time limits for selecting a QME when a valid replacement request is made?
The time limits for unrepresented and represented employees to select or strike a QME are tolled until the replacement QME name or panel is issued.
222
What must a selected medical evaluator provide when requested by a party or by the Medical Director?
Either a complete medical evaluation or a written statement explaining why they believe they are not qualified to address the disputed issues.
223
What happens if parties in a represented case have struck two QME names from a panel and then a valid ground arises to replace the remaining QME?
None of the QMEs whose names appeared on the earlier QME panel shall be included in the replacement QME panel.
224
Under what circumstances can an additional panel of QME physicians in a different specialty be issued?
An additional panel can be issued upon a showing of good cause, such as a written agreement by the parties, a referral from an acupuncturist, an order by a Workers' Compensation Administrative Law Judge, or an agreement reached with the assistance of an Information and Assistance Officer in an unrepresented case.
225
Who can assist parties in reaching an agreement for an additional QME evaluator in another specialty?
An Information and Assistance Officer can assist the parties in reaching an agreement for an additional QME evaluator in another specialty.
226
What should parties do if a new medical dispute arises after a comprehensive medical-legal report has been issued?
The parties should obtain a follow-up evaluation or a supplemental evaluation from the same evaluator, to the extent possible.
227
What is required for parties in an unrepresented case to obtain an additional QME evaluator in another specialty?
The parties must confer with an Information and Assistance Officer, explain the need for an additional evaluator, and reach an agreement on the specialty requested in the presence of the Officer.
228
Under what circumstances can a QME obtain a consultation for an opinion regarding permanent disability?
A QME may obtain a consultation for an opinion regarding permanent disability only if the consultation is necessary to resolve complex medical issues and is approved by the Medical Director as per subdivision 32(a).
229
What should a QME do if they will be unavailable for comprehensive medical evaluations for more than 14 days?
The QME must notify the Medical Director by submitting the Notice of Qualified Medical Evaluator Unavailability form at least 30 days in advance.
230
What does the Medical Director do upon receiving an order from a Workers' Compensation Administrative Law Judge for additional evaluations?
The Medical Director shall issue a panel of Qualified Medical Evaluators.
231
What must an acupuncturist do if they determine that another specialty is required to assess disability?
The acupuncturist shall notify the parties to the examination and refer them to the Medical Unit to request an additional panel.
232
What information must the order from the Appeals Board specify when requesting additional QME evaluations?
The order must specify the residential or employment-based zip code, the specialty for the QME panel, and who shall select a new specialty if needed.
233
What does the Medical Director do upon receiving an order for an additional QME evaluation from the Appeals Board?
The Medical Director shall issue a panel of Qualified Medical Evaluators as specified in the order.
234
What must an acupuncturist do if another specialty is required to determine disability?
The acupuncturist must notify the parties involved and refer them to the Medical Unit to request an additional panel.
235
Can a QME perform new evaluation examinations while in unavailable status?
No, a QME who is unavailable shall not perform any new evaluation examinations until they return to active QME status.
236
What is the time frame for a QME to notify the Medical Director of unavailability?
A QME must notify the Medical Director at least thirty (30) days prior to the period of unavailability.
237
What must a QME provide when requesting unavailable status?
The QME must provide a list of all comprehensive medical/legal evaluation examinations already scheduled during the requested unavailable status period.
238
What happens if a QME fails to notify the Medical Director of their unavailability?
If a QME fails to notify the Medical Director, they may be designated as unavailable for thirty (30) days from when the Medical Director learns of the unavailability.
239
What may happen if a QME has unavailability notifications totaling more than 120 days without good cause?
The QME may be denied reappointment subject to section 51(a)(3).
240
What constitutes good cause for a QME to be granted unavailable status within the 30-day notice period?
Good cause includes medical or family emergencies or the QME's inability to schedule new medical-legal evaluation appointments within 90 days of the initial appointment request.
241
What constitutes a 'new medical-legal evaluation appointment'?
A new medical-legal evaluation appointment is one that is not currently scheduled at the time the physician requests unavailability status.
242
What are acceptable reasons for a QME to be granted unavailable status?
Acceptable reasons include medical or family emergencies, or inability to schedule new medical-legal evaluation appointments within 90 days due to existing commitments.
243
What must a QME do within 5 business days after scheduling a comprehensive medical evaluation appointment?
The QME must complete an appointment notification form and submit it to the employee and the claims administrator, or the employer if there is none.
244
Who is responsible for arranging a Certified Interpreter for a QME appointment?
The party who is to pay the cost is responsible for arranging the Certified Interpreter.
245
Under what circumstances can an evaluator cancel a scheduled appointment?
An evaluator can cancel a scheduled appointment less than six business days prior to the appointment date only for good cause.
246
What happens if a QME fails to comply with the appointment notification requirement?
Failure to comply with the appointment notification requirement shall constitute grounds for denial of reappointment.
247
What should the QME include in the appointment notification regarding interpreter services?
The QME should specify whether a Certified Interpreter is required and indicate the language.
248
What is the minimum notice period required for a QME to cancel a scheduled appointment?
A QME shall not cancel a scheduled appointment less than six (6) business days prior to the appointment date, except for good cause.
249
What is the requirement for a QME to schedule an appointment for a comprehensive medical-legal examination?
The appointment must be conducted at a medical office listed on the panel selection form or any office listed with the Medical Director, provided there is written agreement by the parties to use a different office.
250
What is the time limit for a QME to be placed on unavailable status after a certified letter is mailed?
The time a QME is placed on unavailable status counts toward the one hundred and twenty (120) day limit in section 33(a).
251
What information must the claims administrator provide to the evaluator?
The claims administrator must provide all records prepared or maintained by the employee's treating physician or physicians.
252
What is the minimum notice period required to cancel or reschedule an appointment with an evaluator?
An appointment shall not be cancelled or rescheduled less than six (6) business days before the appointment date, except for good cause.
253
What must be included in a written cancellation of an appointment scheduled by an evaluator?
The written cancellation must state the reason for the cancellation and be served on the opposing party.
254
What is the time frame within which a QME or AME must reschedule a canceled appointment?
A QME or AME must reschedule the appointment within sixty (60) calendar days of the date of the cancellation, unless the parties agree in writing to a later date.
255
What happens if an appointment is cancelled for good cause?
An injured worker shall not be liable for any missed appointment fee whenever an appointment is cancelled for good cause.
256
What information is required to be provided to the evaluator by the claims administrator or employer?
The claims administrator or employer shall provide all records prepared or maintained by the employee's treating physician or physicians.
257
Under what circumstances can an evaluator cancel an appointment without good cause?
Failure to receive relevant medical records prior to a scheduled appointment does not constitute good cause for cancellation, unless the evaluator is a psychiatrist or psychologist who requires those records for a full and fair evaluation.
258
How many business days before an appointment can it be canceled or rescheduled by a party or their attorney?
An appointment cannot be canceled or rescheduled by a party or their attorney less than six (6) business days before the appointment date, except for good cause.
259
Under what condition can a QME or AME cancel an appointment due to not receiving relevant medical records?
Failure to receive relevant medical records does not constitute good cause for cancellation, unless the evaluator is a psychiatrist or psychologist performing an evaluation regarding a disputed injury to the psyche and states that receipt of the records was necessary for a full and fair evaluation.
260
How is the date of cancellation determined if it is mailed?
The date of cancellation is determined from the date of postmark if mailed.
261
What is required when the evaluation is for injuries that occurred before January 1, 2013?
The evaluation requires a copy of the treating physician's report recommending medical treatment, all supporting documents, and the claims administrator's decision regarding the disputed treatment.
262
For injuries that occurred before January 1, 2013, what documentation is needed concerning a disputed utilization review decision?
Documentation needed includes a copy of the treating physician's report recommending medical treatment, the claims administrator's decision regarding the treatment, and all relevant communications during the utilization review process.
263
How should communications with the evaluator be handled according to the regulations?
All communications by the parties with the evaluator must be in writing and sent simultaneously to the opposing party.
264
What must represented parties who have selected an Agreed Medical Evaluator agree on?
They must agree on what information is to be provided to the Agreed Medical Evaluator.
265
What type of records must be provided to the evaluator at least 20 days before the evaluation?
Other medical records relevant to the medical issue(s) in dispute, a letter outlining the medical determination of the primary treating physician, and any non-medical records that are relevant.
266
What type of records, besides medical records, may be relevant to the determination of medical issues in dispute?
Non-medical records, including films and videotapes.
267
What type of records must be included for the determination of medical issues in dispute?
Other medical records, including previous treatment records or information relevant to the medical issue(s) in dispute.
268
What is required to be served on the opposing party at least 20 days prior to the evaluation?
A letter outlining the medical determination of the primary treating physician or the compensability issue(s) that the evaluator is requested to address.
269
What does Labor Code section 4062.3(f) allow regarding communications with an agreed medical evaluator?
It allows for oral or written communications with an AME physician or the physician's staff about nonsubstantive matters such as scheduling appointments and furnishing records.
270
What is the communication requirement for parties with the evaluator?
All communications by the parties with the evaluator shall be in writing and sent simultaneously to the opposing party.
271
How far in advance must information be served to the opposing party before being provided to the evaluator?
At least twenty (20) days before the information is to be provided to the evaluator.
272
How should records be handled when provided to an evaluator to ensure compliance with health and safety guidelines?
Records should not be served directly on the injured employee but may be provided to a designated health care provider, and the injured employee must be notified in writing of this option.
273
What must the claims administrator attach when sending records to the opposing party?
The claims administrator must attach a log that identifies each record or information being sent to the evaluator and lists each item in the order it is attached. This log ensures transparency and accountability in the exchange of information.
274
What can either party use to establish the accuracy of non-medical records before the evaluation?
Either party may use discovery to establish the accuracy or authenticity of non-medical records or information prior to the evaluation.
275
What should be done with records provided to an evaluator?
Records should be given to a designated health care provider, and the injured employee must be informed in writing about this option.
276
What constitutes ex parte communication in the context of sending records to the evaluator?
Failure to send copies of all records being sent to the evaluator to all parties constitutes ex parte communication.
277
What types of reports cannot be forwarded to the evaluator?
Reports that cannot be forwarded include any medical/legal report rejected as untimely, reports from physicians other than treating or evaluators unless ruled admissible, and any medical report or record found inadequate or inadmissible by a Workers' Compensation Administrative Law Judge.
278
What happens if the opposing party objects to any non-medical records proposed to be sent to an evaluator?
If the opposing party objects within 10 days, those records and information shall not be provided to the evaluator unless ordered by a Workers' Compensation Administrative Law Judge.
279
What language must be included in the cover letter when providing information to the employee?
The cover letter should inform the employee to review the enclosed information carefully, as it may be used by the evaluating doctor for the workers' compensation claim. The employee must notify if they do not want the doctor to see this information within 10 days.
280
What must parties do if they want to establish the accuracy of non-medical records before the evaluation?
Either party may use discovery to establish the accuracy or authenticity of non-medical records or information prior to the evaluation.
281
What is the time frame for sending medical information to the QME for unrepresented employees?
The unrepresented employee must be served all non-medical information 20 days prior to the information being served on the QME.
282
What is the time frame for sending medical information to the QME as per subsection (c)?
The time frame is 20 days for sending medical information, provided that the unrepresented employee is served all non-medical information 20 days prior to it being served on the QME.
283
What happens if a party communicates with an evaluator in violation of Labor Code section 4062.3?
The Medical Director shall provide the aggrieved party with a new panel to select a new QME, or the aggrieved party may elect to proceed with the original evaluator.
284
Why is it important for an evaluator to document consultations with treating physicians in their report?
The evaluator shall note any new or additional information received from the treating physician in the report.
285
What should an evaluator do if relevant medical records are not received within 10 days after the evaluation date?
The evaluator shall complete and serve the report to comply with the statutory time frames and note in the report that the records were not received within the required time period.
286
Can an evaluator conduct a supplemental evaluation without an additional physical examination?
Yes, the evaluator need not conduct an additional physical examination if they believe a review of the additional records is sufficient.
287
What provisions apply to claims involving a date of injury prior to 1/1/2005 where the injured worker is represented by an attorney?
The provisions of this section do not apply to the communications between a party and the QME selected by that party.
288
What are the options for a party if there is a violation of Labor Code section 4062.3?
The Medical Director shall provide the aggrieved party with a new panel to select a new QME, or the aggrieved party may elect to proceed with the original evaluator.
289
In claims involving injuries prior to 1/1/2005, what is the communication rule for parties represented by an attorney?
The provisions of this section do not apply to communications between a party and the QME selected by that party.
290
Do communications made by the employee during the examination provide grounds for a new evaluator?
No, unless the Appeals Board has made a specific finding of an impermissible ex parte communication.
291
Can the evaluator conduct a supplemental evaluation after receiving relevant medical records?
Yes, the evaluator shall complete a supplemental evaluation when the relevant medical records are received, and may not need to conduct an additional physical examination if a review of the records is sufficient.
292
What happens if relevant medical records are not provided within 10 days after the evaluation?
The evaluator shall complete and serve the report, noting that the records were not received within the required time period.
293
What must the evaluator note in the report regarding consultations with the employee's treating physician?
The evaluator shall note any new or additional information received from the treating physician in the report.
294
What must the evaluator address regarding contested medical issues?
The evaluator must address all contested medical issues arising from injuries reported on claim forms prior to the employee's appointment, within their scope of practice and clinical competence.
295
What form must the evaluator complete if they find the injured worker permanent and stationary with permanent partial disability?
The evaluator must complete the Physician's Report of Permanent and Stationary Status and Work Capacity (DWC-AD Form 10133.36) and serve it on the claims administrator together with the medical report.
296
What is required for a new QME panel to be issued in another specialty?
A party's request for an additional panel, along with the evaluator's written notice of disputed issues, or an order by a Workers' Compensation Administrative Law Judge, is required for the Medical Director to issue a new QME panel.
297
What should parties do if a new injury or illness is claimed involving the same body part and the same parties?
The parties should utilize, to the extent possible, the same evaluator who reported previously.
298
What must the evaluator do regarding disputed medical issues outside their scope of practice?
The evaluator must advise the parties in writing of any disputed medical issues outside their scope of practice and competency at the earliest opportunity and no later than the date the report is served.
299
What must each evaluation examination and report comply with according to Labor Code sections 4060 to 5703.5?
Each evaluation examination and report must be performed in compliance with all appropriate evaluation procedures pursuant to the specified Chapter.
300
What information must the reporting evaluator include in the comprehensive medical-legal report?
The reporting evaluator must state the date the examination was completed and the street address where the examination was performed.
301
What should the evaluator do if they sign the report on a date different from the examination date?
The evaluator shall enter the date the report is signed next to or near the signature on the report.
302
What should an evaluator include in their report regarding discrimination?
Each reporting evaluator shall include in the report a declaration under penalty of perjury that the evaluator did not discriminate in any way against the parties to the action or the injured worker in the evaluation process or in the content of the report.
303
What must an Agreed Medical Evaluator's opinion be consistent with when providing a report on a disputed medical treatment issue for injuries before January 1, 2013?
The evaluator's opinion shall be consistent with and apply the standards of evidence-based medicine set out in the Medical Treatment Utilization Schedule.
304
What is the requirement for evaluations performed on or after July 1, 2013, regarding opinions on disputed medical treatment issues?
An Agreed Medical Evaluator or Qualified Medical Evaluator shall not provide an opinion on any disputed medical treatment issue, but shall provide an opinion about whether the injured worker will need future medical care to cure or relieve the effects of an industrial injury.
305
What should an evaluator do if the disputed medical treatment is not addressed by the Medical Treatment Utilization Schedule?
The evaluator's medical opinion should be consistent with and refer to other evidence-based medical treatment guidelines, peer-reviewed studies, and articles, and explain the medical basis for their reasoning and conclusions.
306
Where should the deposition be held if requested by an unrepresented injured worker?
The deposition should be held at the location where the evaluation examination was performed or at a facility chosen by the deposing party that is not more than 20 miles from that location.
307
What is the role of an Agreed Medical Evaluator or Qualified Medical Evaluator for evaluations performed on or after July 1, 2013?
They shall not provide an opinion on any disputed medical treatment issue but shall provide an opinion about whether the injured worker will need future medical care to cure or relieve the effects of an industrial injury.
308
What declaration must each reporting evaluator include in their report?
Each reporting evaluator must include a declaration under penalty of perjury that they did not discriminate in any way against the parties to the action or the injured worker in the evaluation process or in the content of the report.
309
What standards must an evaluator's opinion be consistent with for evaluations performed for injuries before January 1, 2013?
The evaluator's opinion must be consistent with and apply the standards of evidence-based medicine set out in the Medical Treatment Utilization Schedule.
310
What is the time frame within which an evaluator must make themselves available for deposition after notice?
The evaluator must make themselves available for deposition within at least one hundred twenty (120) days of the notice of deposition.
311
What is considered a medical-legal expense according to the article?
A medical-legal expense includes costs incurred for X-rays, laboratory fees, diagnostic tests, medical reports, medical records, medical testimony, and interpreter’s fees for proving or disproving a contested claim.
312
What conditions indicate the existence of a contested claim?
A contested claim exists if the employer rejects liability for a claimed benefit, fails to accept liability after a reasonable decision period, or fails to respond to a demand for payment after the statutory period.
313
Under what circumstances do costs of medical evaluations and diagnostic tests qualify as medical-legal expenses?
They qualify as medical-legal expenses only if the medical report can prove or disprove a disputed medical fact essential to adjudicating the employee’s claim for benefits.
314
What is required if an injured employee cannot communicate effectively with an examining physician?
The injured employee is entitled to the services of a qualified interpreter during the medical examination, and the employer or insurance carrier must pay for these services upon request.
315
Under what conditions is an employer not required to pay for interpreter services?
An employer is not required to pay for services of a provisionally certified interpreter unless they consent in advance to the selection or if the injured worker requires interpreting in a language not designated by law.
316
What are the requirements for an employer regarding interpreter services for injured employees?
An employer must pay for interpreter services unless the interpreter is provisionally certified and the employer has not consented to the selection or the injured worker requires a language not designated by law.
317
What must the medical-legal report disclose regarding the evaluation performed?
The report must disclose the date and location of the evaluation, that the signing physician performed the evaluation, and whether it complied with established guidelines.
318
What should be included in the report if the evaluation or time spent was not in compliance with guidelines?
The report must explain in detail any variance and the reasons for it.
319
What is required of the physician if the initial outline of a patient's history is not done by them?
The physician must review the excerpts and the entire outline and make additional inquiries and examinations as necessary.
320
What charges are permissible in relation to the physician's professional services and medical tests?
No amount may be charged in excess of the direct charges for the physician's professional services and reasonable costs of laboratory examinations, diagnostic studies, and clerical expenses.
321
Who is allowed to examine the injured employee or participate in the preparation of the medical-legal report?
Only the physician who signs the medical-legal report or a nurse performing routine functions, such as taking blood pressure.
322
What civil penalty can a physician face for knowingly failing to comply with the requirements of the medical-legal report?
A civil penalty of up to one thousand dollars ($1,000) for each violation.
323
What actions can be taken against a physician assessed a civil penalty under the compliance section?
The physician may be terminated, suspended, or placed on probation as a qualified medical evaluator.
324
What are the consequences of failing to comply with the requirements for producing a medical-legal report?
The report will be inadmissible as evidence and any liability for payment of medical-legal expenses incurred in connection with the report will be eliminated.
325
What must a person billing for medical-legal evaluations specify?
The amount paid or to be paid to persons performing evaluations, procedures, or services not employed by the reporting physician.
326
What happens if a physician fails to comply with the requirements of the report section?
The report becomes inadmissible as evidence and eliminates any liability for payment of medical-legal expenses incurred in connection with the report.
327
What is the minimum number of active QMEs required in a specialty to issue a panel?
There must be at least five active QMEs in the specialty at the time the panel selection is requested.
328
What should happen if there are less than five active QMEs in a requested specialty?
The Medical Director shall contact the party who holds the legal right to designate the specialty for an alternate specialty selection.
329
What happens if a QME informs the Medical Director of their unavailability?
The Medical Director shall exclude that QME from the panel selection process.
330
What procedures does the Medical Director follow when receiving multiple QME panel selection forms that designate different physician specialties?
The Medical Director will issue a panel in the specialty of the treating physician if one party requests that specialty, unless supported by documentation for a different specialty. If no party requests the treating physician's specialty, the Medical Director will select an appropriate specialty for the medical issue in dispute.
331
What can either party do if the Medical Director is unable to issue a QME panel within thirty calendar days?
Either party may seek an order from a Workers' Compensation Administrative Law Judge that a QME panel be issued, specifying the specialty of the QME panel or the party to select the specialty.
332
What is the timeframe for an unrepresented employee to select a QME from the panel list?
The unrepresented employee must select a QME from the panel list within ten (10) days of having been furnished with the form.
333
Who is prohibited from discussing the selection of the QME with an unrepresented worker?
Neither the employer, nor the claims administrator nor any other representative of the employer shall discuss the selection of the QME with an unrepresented worker who has the legal right to select the QME.
334
What happens if an unrepresented employee fails to select a QME within ten days of the issuance of a QME panel?
If the unrepresented employee fails to select a QME or schedule an appointment, the claims administrator may schedule an appointment with a panel QME as provided in Labor Code section 4062.1(c) and shall notify the employee of the appointment.
335
What is the maximum time frame for a QME to schedule an examination after a request?
The QME must schedule an examination within sixty (60) days of the initial request, or ninety (90) days if the 60-day limit has been waived.
336
What happens if the represented employee fails to schedule the QME appointment within the specified time?
The claims administrator or the administrator's attorney may arrange the appointment and notify the employee and the employee's attorney.
337
What is one reason a replacement QME may be selected at random by the Medical Director?
If the evaluator who previously reported in the case is no longer available.
338
What happens if the represented employee fails to schedule the appointment with the QME within ten business days?
If the represented employee fails to schedule the appointment within ten business days, the claims administrator or administrator's attorney may arrange the appointment and notify the employee and employee's attorney of the scheduled date and time.
339
Under what circumstances can a replacement QME be requested according to section §31.5?
A replacement QME can be requested if a QME does not practice in the requested specialty, cannot schedule an exam within the required time, the injured worker has changed residence, or if there are conflicts such as group practice membership. Section §31.5 outlines these specific conditions.
340
What should a represented employee do after the conferring and striking processes are completed according to Labor Code section 4062.2(c)?
After the conferring and striking processes, where both parties discuss and eliminate QMEs from the panel list, the represented employee shall schedule the appointment with the physician selected from the QME panel within ten (10) business days.
341
What should be done if a QME on the panel is the employee's primary treating physician?
A replacement QME should be requested as the QME named on the panel cannot be the employee's primary treating physician for the injury currently in dispute. This is to ensure an unbiased evaluation.
342
What should be done if a QME on the panel is a member of the same group practice as another QME on the panel?
A replacement QME should be requested because having two QMEs from the same group practice could lead to a conflict of interest, affecting the impartiality of the evaluation.
343
Under what circumstances can a replacement QME be requested?
A replacement QME can be requested if the original QME does not practice in the requested specialty, cannot schedule within 60 days, the injured worker has changed residence, or if other specific conditions apply. A QME, or Qualified Medical Evaluator, is a physician certified to evaluate medical-legal issues in workers' compensation cases.
344
Under what condition will an evaluator not be replaced for violating section 34 of Title 8 of the California Code of Regulations?
The evaluator will not be replaced if the request for a replacement is made more than fifteen calendar days from when the party became aware of the violation or when the report was served.
345
What must a party attach to a request for a replacement if the evaluator failed to meet deadlines specified in Labor Code section 4062.5?
A copy of the party's objection to the untimely report.
346
What documents must be submitted for the Medical Director to determine the appropriateness of a specialty for a disputed medical issue?
A copy of the Doctor's First Report of Occupational Injury or Illness (Form DLSR 5021) and the most recent DWC Form PR-2 or a narrative report filed in lieu of the PR-2.
347
What happens if a selected medical evaluator refuses to provide a complete medical evaluation when requested?
The evaluator must provide a written statement explaining why they believe they are not medically qualified or competent to address one or more issues in dispute.
348
Under what condition can the Medical Director issue an additional panel of QME physicians in a different specialty?
The Medical Director shall issue an additional panel if there is a showing of good cause that a panel of QME physicians in a different specialty is needed to assist the parties in resolving disputed medical issues.
349
What is the time limit for an unrepresented employee to select a QME after a valid replacement request is made?
The time limit for an unrepresented employee to select a QME and schedule an appointment is tolled until the date the replacement QME name or QME panel is issued.
350
What must parties do when a new medical dispute arises after a comprehensive medical/legal report has been issued?
The parties shall obtain a follow-up evaluation or a supplemental evaluation from the same evaluator, to the extent possible.
351
What happens if two QME names are struck from a panel in a represented case and a valid ground for replacement arises?
None of the QMEs whose names appeared on the earlier QME panel shall be included in the replacement QME panel.
352
In an unrepresented case, what must the parties do to request an additional QME evaluator in another specialty?
The parties must confer with an Information and Assistance Officer, explain the need for an additional QME evaluator, and reach an agreement on the specialty requested in the presence of the Officer.
353
What is required for an additional comprehensive medical legal report by an evaluator in a different specialty in a represented case?
A written agreement by the parties that there is a need for an additional comprehensive medical legal report by an evaluator in a different specialty.
354
What can a Workers' Compensation Administrative Law Judge order regarding QME physicians?
The judge can order a panel of QME physicians and designate a party to select the specialty or state the specialty to be selected along with the zip code for random selection.
355
What must an AME or QME do if they recommend a new evaluator in another specialty?
The AME or QME must advise the parties and the Medical Director that they have completed or will complete a timely evaluation but recommend a new evaluator for disputed medical conditions outside their clinical competence.
356
What should the referring evaluator do upon receipt of the consulting physician's report?
The referring evaluator shall review the consulting physician's report, incorporate it by reference into the medical-legal report, and comment on the consulting physician's findings and conclusions.
357
Under what conditions can a QME obtain a consultation regarding permanent disability and apportionment?
No QME may obtain a consultation for the purpose of obtaining an opinion regarding permanent disability and apportionment, except as provided in subdivision 32(a).
358
What is the time frame for the Medical Director to issue a panel upon request by a QME acupuncturist?
The Medical Director shall issue a panel within fifteen (15) days of the request.
359
What happens if a consulting physician's report is not received in time for the referring QME to comply with the specified time periods?
The referring QME shall serve the comprehensive medical-legal report timely and, upon receipt of the consulting physician's report, issue a supplemental report within fifteen (15) calendar days that incorporates the consulting physician's report by reference.
360
What type of communications are exempt from the requirement to be made in writing between an injured worker and the consulting physician?
Verbal communications between an injured worker and the consulting physician in the course of the consulting examination are exempt.
361
What information must the order specify when requesting a panel of QMEs?
The residential or employment-based zip code for random selection, the specialty for the QME panel, and who will select a new specialty if necessary.
362
What is the maximum period a QME can be unavailable to schedule or perform evaluations during a one-year fee period?
Up to a maximum of 90 days.
363
What must the Medical Director issue upon receipt of an order from a Workers' Compensation Administrative Law Judge or the Appeals Board?
A panel of Qualified Medical Evaluators.
364
How much notice must a QME give the Medical Director before their period of unavailability begins?
At least 30 days.
365
Under what circumstances can the Medical Director grant unavailable status within the 30-day notice period?
For good cause, including medical or family emergencies.
366
What is the consequence if a QME fails to notify the Medical Director of unavailability at least thirty days prior?
The Medical Director may designate the QME to be unavailable at that location for thirty days from the date the Medical Director learns of the unavailability.
367
What must a QME provide to the Medical Director when requesting unavailable status?
A QME must provide a list of any and all comprehensive medical/legal evaluation examinations already scheduled during the time requested for unavailable status.
368
What constitutes good cause for a QME's unavailability?
Good cause includes sabbaticals, or death or serious illness of an immediate family member.
369
What happens if a party cannot obtain an appointment with a selected QME within sixty days?
That party may waive the right to a replacement in order to accept an appointment no more than ninety days after the date of the initial appointment request.
370
What action does the Medical Director take if notified that a QME is not available?
A certified letter will be sent to the QME regarding his/her unavailability, and if no response is received within fifteen days, the QME will be made unavailable at that location.
371
What happens if an Agreed Medical Evaluator cancels an appointment?
The Agreed Medical Evaluator must reschedule the appointment within sixty (60) calendar days of the cancellation, unless the parties agree in writing to a later date.
372
Under what condition can a QME move an evaluation appointment to another medical office?
The appointment may be moved to another medical office of the selected QME if it is listed with the Medical Director as an additional office location and upon written request by the injured worker for their convenience.
373
What is the minimum notice period required for an evaluator to cancel a scheduled appointment?
An evaluator must not cancel a scheduled appointment less than six (6) business days prior to the appointment date, except for good cause.
374
What must a QME do within 5 business days after scheduling an appointment for a comprehensive medical evaluation?
The QME must complete and submit an appointment notification form to the employee and the claims administrator, or the employer if there is none.
375
Does failure to receive relevant medical records constitute good cause for an evaluator to cancel an appointment?
No, failure to receive relevant medical records does not constitute good cause for cancellation unless the evaluator is a psychiatrist or psychologist performing an evaluation regarding a disputed injury to the psyche.
376
What is the time frame for rescheduling an appointment after a cancellation by an Agreed Panel QME or QME?
The appointment must be rescheduled to a date within thirty (30) calendar days of the cancellation.
377
How should communications with the evaluator be conducted according to the regulations?
All communications by the parties with the evaluator must be in writing and sent simultaneously to the opposing party, except as otherwise provided in specific subdivisions.
378
What information must the claims administrator or employer provide to the evaluator in a workers' compensation case?
The claims administrator or employer must provide all records prepared or maintained by the employee's treating physician, other relevant medical records, a letter outlining the issues for evaluation, and any relevant non-medical records.
379
What must represented parties agree on when selecting an Agreed Medical Evaluator or an Agreed Panel QME?
Represented parties must agree on what information is to be provided to the AME or the Agreed Panel QME as part of their agreement.
380
What can either party use to establish the accuracy or authenticity of non-medical records prior to evaluation?
Discovery.
381
What should the claims administrator include in the cover letter when providing information to the employee?
A clear statement that the enclosed information may be used by the doctor evaluating the medical condition related to the workers' compensation claim, and instructions on how to object within 10 days.
382
What happens if the opposing party objects to any non-medical records within 10 days?
Those records and that information shall not be provided to the evaluator unless ordered by a Workers' Compensation Administrative Law Judge.
383
What is the role of the Appeals Board in disputes regarding ex parte communications?
The Appeals Board retains jurisdiction to determine disputes arising from objections and whether ex parte contact in violation of Labor Code section 4062.3 has occurred.
384
What occurs if a party communicates with an evaluator in violation of Labor Code section 4062.3?
The Medical Director shall provide the aggrieved party with a new panel to select a new QME, or the aggrieved party may elect to proceed with the original evaluator.
385
Do the provisions of this section apply to communications between a party and their selected QME in claims involving a date of injury prior to 1/1/2005?
No, the provisions of this section do not apply to communications between a party and the QME selected by that party in such claims.
386
What happens if a party fails to provide relevant medical records to the evaluator?
If a party fails to provide relevant medical records within 10 days after the evaluation date, the evaluator shall complete and serve the report, noting that the records were not received in the required time period.
387
What is the time frame for sending medical information to the QME if the employee is unrepresented?
The unrepresented employee is not required to comply with the 20-day time frame for sending medical information, but must be served all non-medical information 20 days prior to it being served on the QME.
388
Can the evaluator consult with the employee's treating physician?
Yes, the evaluator and the employee's treating physician(s) may consult as necessary to produce a complete and accurate report.
389
Under what conditions will the Medical Director issue a new QME panel in another specialty?
The Medical Director will issue a new QME panel in another specialty only upon a party's request for an additional panel with the evaluator's written notice attached, or an order by a Workers' Compensation Administrative Law Judge.
390
What is the time frame for an evaluator to be available for deposition after a party is legally entitled to depose them?
The evaluator shall make himself or herself available for deposition within at least one hundred twenty (120) days of the notice of deposition.
391
What must an evaluator do when sending a written notification to the parties in the case of an Agreed Panel QME or a panel QME?
The evaluator shall send a copy of the written notification provided to the parties to the Medical Director at the same time.
392
What should parties do if a new injury or illness is claimed involving the same type of body part or body system?
The parties shall utilize to the extent possible the same evaluator who reported previously.
393
What standards must an Agreed Medical Evaluator or Qualified Medical Evaluator apply when providing an opinion on a disputed medical treatment issue for evaluations performed on or before June 30, 2013?
The evaluator's opinion shall be consistent with and apply the standards of evidence-based medicine set out in the Medical Treatment Utilization Schedule.
394
Under what circumstances can a physician who is not a QME perform a follow-up evaluation on an unrepresented injured worker?
A physician who is not a QME or no longer a QME cannot perform a follow-up evaluation on an unrepresented injured worker.
395
What forms must be served on the local DEU office along with the QME report?
The forms include QME Form 111, DWC-AD Form 100 (DEU), DWC-AD Form 101 (DEU), DWC-CA form 10232.1, and DWC-CA form 10232.2.
396
What is required for a party to request a supplemental report based on objections to a QME's findings?
The party must send a detailed request directly to the DEU office where the report was served, specifying the reasons for the objection and the need for a supplemental report.
397
What should be done if a QME determines that an unrepresented employee's condition is not permanent and stationary?
The parties shall request any further evaluation from the same QME if the QME is currently active and available
398
When can a QME issue a supplemental report after serving a comprehensive medical-legal report?
A QME can issue a supplemental report only after an initial summary rating report has been issued or if directed by relevant authorities.
399
For injuries occurring on or after January 1, 1979, and prior to April 19, 2004, what is the limit on aggregate disability payments for temporary partial disability?
240 compensable weeks within a period of five years from the date of the injury.
400
For injuries occurring on or after January 1, 2008, what is the limit on aggregate disability payments for temporary disability?
104 compensable weeks within a period of five years from the date of injury.
401
Under what conditions can aggregate disability payments for a single injury occurring on or after April 19, 2004, extend to 240 compensable weeks?
For an employee who suffers from specific injuries or conditions as outlined in the regulations.
402
What is the maximum duration for aggregate disability payments for a single injury causing temporary disability that occurred on or after April 19, 2004?
104 compensable weeks within a period of two years from the date of commencement of temporary disability payment.
403
Can the requirement for work to be located within a reasonable distance from the employee's residence be waived?
Yes, the requirement can be waived by the employee if they accept the work and do not object to the location within 20 days of being informed of the right to object.
404
What is the definition of 'modified work' in relation to employee compensation?
Modified work means regular work modified so that the employee can perform all job functions and offers wages and compensation that are at least 85 percent of those paid at the time of injury, located within a reasonable commuting distance.
405
How is the equivalence of wages and compensation determined for modified or alternative work?
Wages and compensation are considered equivalent if they are at least 85 percent of those paid at the time of injury, excluding any increase in working hours over the average hours worked at that time.
406
What constitutes 'alternative work' for an employee?
Alternative work is defined as work that the employee can perform, offers wages and compensation that are at least 85 percent of those paid at the time of injury, and is located within reasonable commuting distance.
407
What are the maximum voucher amounts for different percentages of permanent partial disability awards?
- Less than 15 percent: Up to $4,000
408
- 15 to 25 percent: Up to $6,000
409
- 26 to 49 percent: Up to $8,000
410
- 50 to 99 percent: Up to $10,000
411
What is the expiration period for a voucher issued on or after January 1, 2013?
The voucher shall expire two years after the date it is furnished to the employee or five years after the date of injury, whichever is later.
412
What expenses can the supplemental job displacement voucher be used for?
The voucher may be used for payment of tuition, fees, books, and other expenses required by the school for retraining or skill enhancement.
413
What is the eligibility criterion for an injured employee to receive a supplemental job displacement benefit?
The injured employee must not return to work for the employer within 60 days of the termination of temporary disability.
414
What are the conditions under which an employer is not liable for supplemental job displacement benefits according to Section 4658.6?
An employer is not liable if they offer modified work or alternative work within 30 days of the termination of temporary disability indemnity payments, and the employee rejects or fails to accept the offer.
415
What are the essential conditions for alternative work to be considered valid under Section 4658.6?
The alternative work must allow the employee to perform essential job functions, last at least 12 months, offer wages within 15 percent of the pre-injury wages, and be located within reasonable commuting distance from the employee's residence at the time of injury.
416
What is the minimum duration for modified work offered by the employer to avoid liability for supplemental job displacement benefits?
The modified work must last at least 12 months.
417
How is an employee's diminished future earning capacity calculated?
It is a numeric formula based on empirical data and findings that aggregate the average percentage of long-term loss of income resulting from each type of injury for similarly situated employees.
418
What is the basis for apportionment of permanent disability according to the section?
Apportionment of permanent disability shall be based on causation.
419
What factors are considered in determining the percentages of permanent disability according to the section?
The nature of the physical injury or disfigurement, the occupation of the injured employee, and the employee's age at the time of the injury, with consideration given to diminished future earning capacity.
420
What publication is referenced for the descriptions and measurements of physical impairments in determining permanent disability?
The American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment (5th Edition).
421
What is the purpose of the schedule for determining permanent disability percentages?
To promote consistency, uniformity, and objectivity in the evaluation of permanent disabilities.
422
How often must the administrative director amend the schedule for determining permanent disability percentages?
At least once every five years.
423
What is presumed if an applicant has received a prior award of permanent disability?
It is conclusively presumed that the prior permanent disability exists at the time of any subsequent industrial injury.
424
What must an employee claiming an industrial injury disclose upon request?
All previous permanent disabilities or physical impairments.
425
What is the employer's liability regarding permanent disability caused by an industrial injury?
The employer is only liable for the percentage of permanent disability directly caused by the injury arising out of and occurring in the course of employment.
426
How should a physician determine the apportionment of permanent disability?
By finding the approximate percentage of permanent disability caused by the injury arising out of employment and the percentage caused by other factors, including prior injuries.
427
What must a physician's report include to be considered complete on the issue of permanent disability?
The report must include an apportionment determination.
428
What should a physician do if they cannot make an apportionment determination?
The physician must state the specific reasons for not making a determination and consult with other physicians or refer the employee to another physician.
429
What regions of the body are considered in the context of total disability as per Section 4662?
The regions include Hearing, Vision, Mental and behavioral disorders, the spine, upper extremities (including shoulders), lower extremities (including hip joints), and other systems or regions not listed.
430
Can the permanent disability rating for multiple injuries from the same industrial accident exceed 100 percent?
No, the permanent disability rating for each individual injury sustained by an employee arising from the same industrial accident cannot exceed 100 percent when added together.
431
What must the evaluator complete if they declare the injured worker permanent and stationary with permanent partial disability?
The evaluator must complete the Physician's Report of Permanent and Stationary Status and Work Capacity (DWC-AD).
432
What must an Agreed Medical Evaluator or Qualified Medical Evaluator's opinion be consistent with when providing a comprehensive medical/legal report on a disputed medical treatment issue?
The evaluator's opinion must be consistent with and apply the standards of evidence-based medicine set out in Division 1, Chapter 4.5, Subchapter 1, sections 9792.20 et seq of Title 8 of the California Code of Regulations (Medical Treatment Utilization Schedule).
433
What must each reporting evaluator include in their report regarding discrimination?
Each reporting evaluator shall include in the report a declaration under penalty of perjury that the evaluator did not discriminate in any way against the parties to the action or the injured worker in the evaluation process or in the content of the report.
434
What should an evaluator do if the disputed medical treatment, condition, or injury is not addressed by the Medical Treatment Utilization Schedule?
The evaluator's medical opinion shall be consistent with and refer to other evidence-based medical treatment guidelines, peer-reviewed studies and articles, and shall explain the medical basis for the evaluator's reasoning and conclusions.
435
How is chronic pain defined in this article?
Chronic pain is defined as pain lasting three or more months from the initial onset of pain.
436
What does ACOEM stand for and what does it provide?
ACOEM stands for the American College of Occupational and Environmental Medicine, and it provides evidenced-based medical treatment guidelines for conditions commonly associated with the workplace.
437
What is a claims administrator in the context of workers' compensation?
A claims administrator is a self-administered workers' compensation insurer, a self-administered self-insured employer, a self-administered legally uninsured employer, a self-administered joint powers authority, a third-party claims administrator, or the California Insurance Guarantee Association.
438
What does Evidence-Based Medicine (EBM) entail?
Evidence-Based Medicine (EBM) entails a systematic approach to making clinical decisions that integrates the best available research evidence with clinical expertise and patient values.
439
What is meant by functional improvement in medical evaluations?
Functional improvement refers to either a clinically significant improvement in activities of daily living or a reduction in work restrictions, as well as a reduction in the dependency on continued medical treatment.
440
What is meant by 'scientifically based' in medical recommendations?
'Scientifically based' means based on scientific literature, wherein the body of literature is identified through a literature search, evaluated, and then used as the basis to support a recommendation.
441
What does 'ODG' stand for and what does it contain?
'ODG' stands for the Official Disability Guidelines published by the Work Loss Data Institute, containing evidenced-based medical treatment guidelines for conditions commonly associated with the workplace.
442
What does 'strength of evidence' refer to?
'Strength of Evidence' establishes the relative weight that shall be given to scientifically based evidence.
443
What does 'nationally recognized' mean in the context of medical guidelines?
'Nationally recognized' means published in a peer-reviewed medical journal or developed, endorsed, and disseminated by a national organization with affiliates based in two or more U.S. states and is the most current version.
444
What is the definition of 'medical treatment' in the context of industrial injury?
Medical treatment is care which is reasonably required to cure or relieve the employee from the effects of the industrial injury consistent with the requirements of sections 9792.20-9792.26.
445
What does 'peer reviewed' mean?
'Peer reviewed' means that a study's content, methodology, and results have been evaluated and approved prior to publication by an editorial board of qualified experts.
446
What are 'medical treatment guidelines'?
Medical treatment guidelines are the most current version of written recommendations systematically developed by a multidisciplinary process through a comprehensive literature search to assist in decision-making about appropriate medical treatment for specific clinical circumstances reviewed and updated within the last five years.
447
What is the Medical Treatment Utilization Schedule (MTUS)?
The MTUS is a schedule adopted by the Administrative Director consisting of sections 9792.20 through 9792.26, based on the principles of Evidence-Based Medicine (EBM) to guide clinical decision making for injured workers.
448
How does the MTUS guide clinical decision making for injured workers?
The MTUS provides a framework for the most effective treatment of work-related illness or injury to achieve functional improvement, return-to-work, and disability prevention.
449
What does the MTUS assert about intuition and unsystematic clinical experience?
The MTUS asserts that intuition, unsystematic clinical experience, and pathophysiologic rationale are insufficient grounds for making clinical decisions.
450
Can treatment be denied solely because a condition is not addressed by the MTUS?
No, treatment shall not be denied on the sole basis that the condition or injury is not addressed by the MTUS.
451
Who bears the burden of proof when seeking treatment outside of the MTUS?
The treating physician who seeks treatment outside of the MTUS bears the burden of rebutting the MTUS' presumption of correctness by a preponderance of scientific medical evidence.
452
What is the presumption of correctness in the MTUS regarding medical treatment?
The recommended guidelines set forth in the MTUS are presumptively correct on the issue of extent and scope of medical treatment, but this presumption is rebuttable.
453
What should be done if a medical condition or injury is not addressed by the MTUS?
Medical care shall be in accordance with other medical treatment guidelines or peer-reviewed studies found by applying the Medical Evidence Search Sequence.
454
What does 'bias' refer to in the context of research?
Bias refers to any tendency to influence the results of a trial or its interpretation other than the experimental intervention.
455
What is a 'case-control study'?
A case-control study is a retrospective observational epidemiologic study of persons with the disease and a suitable control group of persons without the disease.
456
What is meant by 'biologic plausibility'?
Biologic plausibility means the likelihood that existing biological, medical, and toxicological knowledge explains observed effect.
457
What is the purpose of 'blinding' in research?
Blinding is a technique used to eliminate bias by hiding the intervention from the patient, clinician, and any others who are interpreting results.
458
What is a case report?
A detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient, usually describing an unusual or novel occurrence.
459
What does a case-series involve?
A group or series of case reports involving patients who were given similar treatment, containing detailed information about individual patients.
460
What is a cohort study?
An epidemiologic study comparing two or more groups of people free of disease that differ according to exposure to a potential cause of the disease, observing incidence rates over time.
461
What is a confounding variable?
An extrinsic factor associated with the exposure under study that can affect the outcome.
462
What is meant by 'concealment of allocation' in a study?
Precautions taken to ensure that the groups to which patients or subjects are assigned are not revealed prior to their definitive allocation.
463
What characterizes a cross-sectional study?
A study that examines the relationship between diseases and other variables of interest as they exist in a defined population at one particular time, focusing on disease prevalence.
464
What is an 'inception cohort study'?
An inception cohort study means a group of individuals identified for subsequent study at an early, uniform point in the course of the specified health condition, or before the condition develops.
465
What is meant by 'disease incidence'?
Disease incidence means new cases of disease or condition over a period of time.
466
How is 'disease prevalence' defined?
Disease prevalence means the rate of a disease or condition at any particular point in time.
467
What constitutes 'expert opinion' in medical practice?
Expert opinion means a determination by experts, through a process of evidence-based thinking, that a given practice should or should not be recommended, and the opinion is published in a peer-reviewed medical journal.
468
What does the term 'diagnostic test' refer to?
A diagnostic test means any medical test performed to confirm or determine the presence of disease in an individual suspected of having the disease, usually following the report of symptoms or based on the results of other medical tests.
469
What does 'index test' refer to in a study?
Index test means the diagnostic procedure or test that is being evaluated in a study.
470
What is the purpose of post-marketing surveillance?
It is designed to provide information on the actual use of a drug after it has been licensed, including the occurrence of side effects and adverse reactions.
471
What is a meta-analysis?
It is a mathematical process that combines results from two or more studies, providing a weight to each study based on the statistical likelihood that its results are closer to the truth.
472
What is a randomized trial?
It is a clinical experiment where subjects are allocated by chance into study and control groups to receive or not receive an experimental procedure, with results assessed by comparing outcomes.
473
What is meant by 'low risk of bias' in clinical trials?
It refers to trials that contain methodological safeguards to protect against biases related to vested interests and other biases affecting randomization, allocation concealment, selection, blinding, and outcome reporting.
474
What does 'intention to treat' mean in randomized controlled trials?
It means that all patients allocated to a given arm of the treatment regimen are included in the analysis, regardless of whether they received or completed the prescribed regimen.
475
What does prognosis refer to in a medical context?
It refers to the prospect of survival and recovery from a disease based on its usual course or special features of the case.
476
What is 'selective outcome reporting'?
'Selective outcome reporting' is the failure to report all outcomes assessed in a trial, including any post hoc changes in the primary outcome.
477
What is meant by 'risk of bias' in clinical trials?
'Risk of bias' refers to the introduction of bias into trials due to methodological insufficiencies related to vested interests, randomization sequence, allocation concealment, selection, blinding, selective outcome reporting, early stopping, and intention to treat.
478
What are 'treatment benefits'?
'Treatment benefits' are positive patient-relevant outcomes associated with an intervention, quantifiable by epidemiological measures such as absolute risk reduction and number needed to treat.
479
What defines a 'systematic review'?
A 'systematic review' is the application of strategies that limit bias in the assembly, critical appraisal, and synthesis of all relevant studies on a specific topic, focusing on peer-reviewed publications and using rigorous methods.
480
What does the term 'reference standard' refer to in the context of index tests?
The 'reference standard' means the gold standard to which an index test is being compared.
481
How does a systematic review differ from a meta-analysis?
A systematic review does not include a quantitative summary of results, while a meta-analysis may be part of a systematic review.
482
What are 'treatment harms'?
'Treatment harms' are adverse patient-relevant outcomes associated with an intervention, identifiable by epidemiological measures such as absolute increased risk or number needed to harm, and also through post-marketing surveillance.
483
How much of their total practice time must a physician devote to providing direct medical treatment to qualify as a medical evaluator?
A physician must devote at least one-third of total practice time to providing direct medical treatment.
484
What qualifications must a physician meet to be appointed as a qualified medical evaluator?
A physician must be licensed to practice in the state and demonstrate that he or she meets specific requirements outlined in paragraphs (1), (2), (6), and (7), and applicable requirements in paragraphs (3), (4), or (5) if they are a medical doctor, doctor of osteopathy, doctor of chiropractic, or psychologist.
485
What examination must a physician pass prior to being appointed as a qualified medical evaluator?
A physician must pass an examination written and administered by the administrative director to demonstrate competence in evaluating medical-legal issues in the workers' compensation system.
486
What is required for a doctor of chiropractic to be certified in California workers' compensation evaluation?
A doctor of chiropractic must be certified in California workers' compensation evaluation by a provider recognized by the administrative director, and the certification program must include instruction on disability evaluation report writing that meets established standards.
487
What are the qualifications required for a medical doctor to be appointed as a qualified medical evaluator?
A medical doctor must be board certified in a specialty recognized by the administrative director and either the Medical Board of California or the Osteopathic Medical Board of California, have completed an accredited residency training program, have been an active qualified medical evaluator on June 30, 2000, or have equivalent qualifications deemed acceptable by the relevant boards.
488
Can retired physicians or those holding teaching positions be appointed as qualified medical evaluators?
Yes, the administrative director can adopt standards for the appointment of exceptionally well-qualified retired physicians or those holding teaching positions, even if they do not meet all standard qualifications.
489
What are the qualifications required for a board certified clinical psychologist to be recognized by the administrative director?
The psychologist must hold a doctoral degree in psychology or an equivalent degree, have at least five years of postdoctoral experience in diagnosing and treating emotional and mental disorders, and be board certified by a recognized board.
490
What happens if a qualified medical evaluator's report is rejected for failing to meet minimum standards?
If a report is rejected, the workers' compensation administrative law judge or the appeals board must make a specific finding and notify the medical evaluator and the administrative director.
491
What must a qualified medical evaluator complete within the previous 24 months to maintain their status?
A qualified medical evaluator must complete at least 12 hours of continuing education in impairment evaluation or workers' compensation-related medical dispute evaluation approved by the administrative director.
492
What actions can lead to the suspension or termination of a qualified medical evaluator by the administrative director?
The administrative director may suspend or terminate a qualified medical evaluator without a hearing if certain conditions occur, such as the evaluator not meeting the established criteria.
493
