QME Study 2 Flashcards
1
Q
Can a physician who has been terminated due to a revoked license be reappointed as a qualified medical evaluator?
A
No, a physician who has been terminated because their license has been revoked or terminated by the licensing authority cannot be reappointed.
2
Q
What happens if an evaluator's license to practice in California is suspended or revoked?
A
The evaluator is precluded from practice.
3
Q
What right does an employee have if a panel is not assigned within 20 working days?
A
The employee has the right to obtain a medical evaluation from any qualified medical evaluator of their choice within a reasonable geographic area.
4
Q
What is the time frame for the administrative director to notify a physician of the final decision after reviewing their response to a statement of reasons?
A
Within 60 days after receipt of the physician's response.
5
Q
What is the time frame for assigning three-member panels of qualified medical evaluators after a request is made?
A
Within five working days after receiving a request.
6
Q
What information must the form promulgated by the administrative director include for each physician on the panel?
A
The physician's name, address, telephone number, specialty, number of years in practice, and a brief description of his or her qualifications.
7
Q
What must the administrative director provide to a physician upon request regarding termination or denial of appointment as a qualified medical evaluator?
A
A written statement of its reasons for termination or denial.
8
Q
What method does the medical director use for assigning panels of qualified medical evaluators?
A
A random selection method.
9
Q
What should the form state regarding consulting with an information and assistance officer?
A
The form should state that the employee has the right to consult with an information and assistance officer at no cost prior to selecting the doctor for their evaluation.
10
Q
What happens if there are not enough qualified medical evaluators of a requested type within the employee's geographic area?
A
The medical director shall include sufficient qualified medical evaluators from other geographic areas, and the employer must pay all necessary travel costs if the employee selects an evaluator from another area.
11
Q
What criteria must a qualified medical evaluator meet to be included in the list compiled by the medical director?
A
A qualified medical evaluator must not have a conflict of interest, be certified by the administrative director in an appropriate specialty, and must not have been suspended or terminated for failure to pay required fees.
12
Q
What rights does an employee have regarding transportation expenses and temporary disability for examinations?
A
An employee is entitled to receive transportation expenses and temporary disability for each day necessary for the examination.
13
Q
What does 'good cause' refer to in the context of extending the 30-day deadline for medical evaluations?
A
'Good cause' refers to valid reasons that justify the failure to meet the 30-day deadline, allowing for an extension of up to 15 days.
14
Q
What is the maximum timeframe for initial medical evaluations to be prepared and submitted by qualified medical evaluators?
A
The maximum timeframe for initial medical evaluations to be prepared and submitted is no more than 30 days after the evaluator has seen the employee or commenced the medical evaluation procedure.
15
Q
Under what circumstances can the 30-day period for medical evaluations be extended?
A
The 30-day period can be extended if the evaluator has not received test results or consulting physician's evaluations in time, or for good cause by not more than 15 days.
16
Q
What must the medical director submit to the administrative director annually?
A
The medical director must submit an annual report summarizing the results of the continuous review of medical evaluations and reports and make recommendations for improvement.
17
Q
What is the role of the medical director in relation to comprehensive medical evaluations and reports?
A
The medical director continuously reviews the quality and timeliness of comprehensive medical evaluations and reports prepared by agreed and qualified medical evaluators, including a random sample of reports and those alleged to be inaccurate or incomplete.
18
Q
What rights does an employee have regarding the selection of a new evaluator if their current evaluator is unavailable?
A
The employee has the right to the addition of a new evaluator to their panel, selected at random, for each evaluator not available to see them within a specified period of time, but can also waive this right for a specified period thereafter.
19
Q
What procedures must physicians follow when evaluating permanent impairment and limitations resulting from an injury?
A
Physicians must evaluate the existence and extent of permanent impairment and limitations in a manner consistent with Sections 4660 and 4660.1.
20
Q
What are some valid reasons for the unavailability of a qualified medical evaluator?
A
Medical emergencies of the evaluator or evaluator's family, death in the evaluator's family, and natural disasters or other community catastrophes that interrupt the operation of the evaluator's business.
21
Q
What are the requirements for diagnosing a psychiatric injury?
A
The diagnosis of a mental disorder must be expressed using the terminology and criteria of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised, or other nationally accepted psychiatric diagnostic manuals.
22
Q
What procedures govern the determination of disputed medical treatment issues?
A
The determination of any disputed medical treatment issues must be conducted in a manner consistent with Section 5307.27.
23
Q
Under what circumstances can the administrative director suspend or terminate a physician's privilege to serve as a qualified medical evaluator?
A
The administrative director may suspend or terminate the privilege if it is determined, based on substantial evidence, that the evaluator has violated any material statutory or administrative duty or failed to follow established medical procedures or qualifications.
24
Q
What additional standards must a medical evaluator meet for appointment or reappointment?
A
Any additional medical or professional standards that a medical evaluator shall meet as a condition of appointment, reappointment, or maintenance in the status of a medical evaluator.
25
What are the guidelines for the range of time required for a medical-legal evaluation that has not been defined and valued pursuant to Section 5307.6?
The guidelines shall establish minimum times for patient contact in the conduct of the evaluations, consistent with regulations adopted pursuant to Section 5307.6.
26
What must happen within 30 days if a qualified medical evaluator is cited for a violation?
A hearing on the alleged violation must be set within 30 days of service of the citation.
27
What actions can lead to immediate suspension or termination of a physician's privilege as a qualified medical evaluator, and what are the consequences for failing to comply with timeframe standards?
Failing to timely pay the required fee, having their license suspended or revoked by the licensing authority, or failing to comply with timeframe standards may lead to suspension or termination of their privilege to serve as a qualified medical evaluator.
28
What can the administrative director do if a qualified medical evaluator is found in violation of certain standards, and what happens to reports prepared by a suspended or terminated physician?
The administrative director may terminate or suspend the evaluator, or place them on probation with conditions. Reports prepared by a suspended or terminated physician shall not be admissible in any proceeding before the appeals board, and there shall be no liability for payment for the report.
29
What is required for medical-legal evaluations prepared by qualified medical evaluators?
They must meet the minimum standards established by the administrative director or the appeals board.
30
What must a qualified medical evaluator not accept to avoid conflicts of interest?
An evaluator shall not request or accept any compensation or other thing of value that could create a conflict with their duties.
31
What is required for an application for appointment as a QME?
Applications must be submitted on the form in section 100 (QME Form 100) along with any required supporting documentation.
32
What happens to a physician's application for QME appointment if they withdraw while under investigation?
The physician's application shall be subject to having the disciplinary process reactivated whenever a new application for appointment or reappointment is subsequently filed.
33
What must an applicant submit to be certified as eligible to sit for the QME competency examination?
An applicant must submit an application form and supporting documentation that meets all statutory and regulatory eligibility requirements.
34
What is required for Medical Doctors or Doctors of Osteopathy to apply as Qualified Medical Evaluators in California?
They must provide a copy of their certificate of completion of postgraduate specialty training, board certification by a recognized specialty board, or a declaration under penalty of perjury with supporting documentation of equivalent qualifications.
35
What documentation must a psychologist provide to qualify as a Qualified Medical Evaluator in California?
A psychologist must provide a copy of a doctoral degree in psychology or an equivalent degree, along with evidence of at least five years of postdoctoral experience in treating emotional and mental disorders, or proof of having served as an AME on eight or more occasions prior to January 1, 1990, with the same experience requirement.
36
What must applicants report on the SFI Form 124 when applying to become a QME?
Applicants must accurately and fully report their specified financial interests to the best of their knowledge.
37
What is the minimum course requirement for physicians prior to appointment as a QME?
They must complete a course of at least sixteen (16) hours in disability evaluation report writing.
38
What is required for Doctors of Chiropractic to become certified as a QME in California?
They must provide a copy of a current or valid certificate in California Workers Compensation Evaluation with a minimum of 25 hours completed, obtained within the three years prior to the application.
39
What obligation does a QME have regarding treatment during an evaluation exam?
A QME shall not treat or offer to provide medical treatment for the injury for which they have done a QME evaluation, unless a medical emergency arises.
40
What must a QME applicant declare under penalty of perjury regarding their California license?
The applicant must declare that they have an unrestricted California license and are not currently on probation from the state licensing board, or state all restrictions and terms of probation if applicable.
41
What must a QME applicant report on QME Form 124?
The applicant must accurately and fully report the specified financial interest information required by section 29 of Title 8 of the California Code of Regulations.
42
What disciplinary action may be taken against a QME who solicits an injured worker for direct medical treatment?
The QME shall be subject to disciplinary action pursuant to section 60.
43
What is the minimum practice time requirement for a QME applicant providing direct medical treatment?
The applicant must devote at least one-third of their total practice time to providing direct medical treatment during each year of the applicant's term of appointment.
44
Under what conditions does the minimum practice time requirement not apply to a QME applicant?
The requirement does not apply if the applicant served as an AME on 8 or more occasions in the year prior to application or meets the requirements of section 15.
45
What examination must a QME applicant pass?
The applicant must pass the QME Competency Examination, or if an acupuncturist, the QME Competency Examination for acupuncturists.
46
How long does it take for the Administrative Director to inform an applicant of their examination results?
Sixty (60) calendar days from the date the applicant takes the competency examination.
47
What must a physician submit to apply for the QME competency examination?
A properly-completed Application for Appointment Form, the Registration Form for the QME Competency Examination, and the appropriate fee.
48
How much notice must the Administrative Director give before a competency examination?
At least sixty (60) calendar days before the examination.
49
When must an applicant submit their forms to the Administrative Director prior to the competency examination?
At least forty-five (45) calendar days prior to the date of the next scheduled competency examination.
50
How long does the Administrative Director have to inform an applicant if they can take the examination?
Fifteen (15) calendar days from the date the Administrative Director receives the properly-completed forms and appropriate fee.
51
What happens if an applicant is suspected of cheating during the QME examination?
The applicant may be disqualified from the examination and, if found to have cheated, will be denied further admittance to any QME examination for at least five years.
52
What is required for an applicant who fails the competency examination three times?
The applicant must show proof of having completed six hours of continuing education from a course approved by the Administrative Director prior to taking the examination again.
53
What must an applicant do within thirty days of passing the QME competency examination?
An applicant must file the QME Fee Assessment Form including the appropriate fee within thirty days of the date of the notice.
54
How long does an applicant have to appeal a failing grade on a competency exam?
An applicant has from immediately after completing the examination until ten days after the date of the examination results letter to appeal a failing grade.
55
What is an example of potential bias that may be discussed in the anti-bias training for QMEs?
An example of potential gender bias in a fictitious QME evaluation where an apportionment rating is made based on an assumption about a risk factor related solely to the injured worker's gender.
56
What training must an applicant complete before being appointed as a QME?
An applicant must complete a course of at least two (2) hours in anti-bias training.
57
What topics are covered in the anti-bias training course for QMEs?
The course includes instruction on differences in human experience, implicit or unconscious bias, stereotyping, discrimination, and their impact on medical evaluations and reporting.
58
What are the significant procedural errors that can occur in the examination process for QMEs?
Significant procedural errors include unfair discrimination, bias, or fraud.
59
What could be a ground for denying a physician's request to add a specialty?
The failure to provide proof of board certification shall be grounds to deny the request.
60
What documentation must a physician provide to be listed as a QME in a particular specialty?
The physician must provide documentation from the relevant board of certification or qualification recognized by the physician's licensing board.
61
What is the minimum passing rate required for credit in the course mentioned?
The minimum passing rate required for credit in the course is no lower than 70 percent correct responses.
62
What must a physician do to request the addition or removal of a medical specialty?
All requests by a physician to add or remove a medical specialty shall be in writing, including the required documentation that establishes board certification.
63
What is a potential impact of gender bias on the evaluation of permanent disability resulting from industrial breast cancer?
Gender bias could potentially lead to an inaccurate assessment of the impairment that results from breast cancer and its treatment.
64
What qualifications must a retired physician meet to be eligible for appointment as a QME?
A retired physician must retain a current license to practice in California, have a minimum of 25 years' experience in their practice, and at least 10 years' experience in workers' compensation medical issues.
65
What are the criteria for a current salaried faculty member to qualify for appointment as a QME?
The faculty member must have a current license to practice as a physician, be engaged in teaching, lecturing, published writing, or medical research in their specialty for at least one-third of their professional time, and their practice in the three years prior to application must not have been solely devoted to forensic evaluation of disability.
66
What is required for a physician to be considered for appointment as a QME according to Labor Code Section 139.2(c)?
A physician must pass the QME competency examination and submit written documentation to the Administrative Director that they meet either criteria (a), (b), or (c).
67
What is a requirement regarding the practice of a physician in the three years preceding the application?
The physician's practice shall not have been devoted solely to the forensic evaluation of disability.
68
What is the maximum number of hours per week a physician can practice direct medical treatment to be eligible for certain requirements?
Fewer than 10 hours per week.
69
What experience is required for a physician applying for reappointment as a QME?
The physician must have 10 years of experience in workers' compensation medical issues.
70
What form must be included in the reappointment application for physicians?
A Reappointment Application Form in section 104.
71
What must a retired physician do to maintain their status as a Qualified Medical Evaluator (QME)?
Notify the Administrative Director of changes in status and complete continuing education requirements prior to reappointment.
72
What may the Administrative Director do regarding QMEs' continuing education documentation?
The Administrative Director may randomly audit QMEs for documentation of program attendance to support compliance.
73
What may happen to a Reappointment Application Form if it is incomplete?
It may be rejected if it is incomplete or does not contain the required supporting documentation.
74
What must a QME attest regarding their medical license when applying for reappointment?
That their license is neither restricted nor encumbered by suspension or probation and that they will notify the Administrative Director of any changes.
75
What must a QME attest to regarding their financial interests when applying for reappointment?
That they have accurately reported their specified financial interests on the QME SFI Form 124 to the best of their knowledge.
76
What must a QME submit when applying for reappointment?
A statement signed under penalty of perjury attesting to the completion of continuing education requirements and providing details of the programs attended.
77
What information must be included in the continuing education statement submitted by a QME?
The dates, locations, titles of the programs, names of providers, and number of hours of attendance for each program.
78
What may lead to a QME being denied reappointment?
A QME who has failed to cooperate with an investigation into their practice as a QME may be denied reappointment at the discretion of the Administrative Director.
79
What can happen if there is prima facie evidence of a violation of a statute, duty, or regulation by a QME?
The Administrative Director may, at their discretion, reappoint or deny reappointment to the evaluator.
80
What must a physician submit along with their reappointment application?
The physician must submit their two most recent medical-legal reports in which there was a face-to-face evaluation.
81
What type of signature can a QME use on the statement required for reappointment?
A QME may use an original signature, an electronic signature as defined in Civil Code section 1633.2, or a digital signature as defined in Government Code section 16.5.
82
What must a physician attest to regarding referrals when applying for QME reappointment?
The physician must attest that they shall abide by all regulations of the Administrative Director and shall refrain from making referrals in violation of those regulations.
83
What must a QME do before affixing their signature to the reappointment statement?
A QME must personally review the content of the statement and verify its truth and accuracy before affixing their signature.
84
What is required for a QME to be reappointed?
A QME must be in compliance with all statutes, duties, and regulations relevant to the QME program in order to be reappointed.
85
What may a physician submit in lieu of the two reports if they did not generate them in the previous two years?
A statement of explanation.
86
On what grounds may the Administrative Director deny reappointment to a QME?
Any grounds that would provide a basis for suspending or terminating a Physician's privilege to serve as a QME, failure to comply with evaluation time frames on at least three occasions during the calendar year, or filing notification for unavailability for more than 120 calendar days during the calendar year.
87
How long can a QME file notification for unavailability before risking denial of reappointment?
For more than 120 calendar days during the calendar year.
88
What is one reason a QME could be denied reappointment related to evaluation time frames?
Failure to comply with the evaluation time frames in sections 34 or 38 on at least three occasions during the calendar year.
89
What are the conditions for counting a rejected evaluation as one of the five rejections?
A rejected evaluation must be final, and the time for appeal must have expired before it can be counted as one of the five rejections.
90
What happens if a QME has more than five evaluations rejected within a two-year period?
If a QME has more than five evaluations rejected within a two-year period, it may lead to disciplinary actions, provided the rejection was based on the failure to prove or disprove a contested issue or comply with regulations.
91
What is the consequence of violating an order or ruling by a Workers' Compensation Judge or the Appeals Board?
A finding that the QME violated an order or ruling by a Workers' Compensation Judge or the Appeals Board can lead to disciplinary actions, provided the finding is final and the time for appeal has expired.
92
What constitutes good cause for refusing to perform a medical-legal evaluation?
Good cause for not performing a medical-legal evaluation includes factors outlined in subsections 41(h) and 41(i) of the regulations.
93
What constitutes a violation in billing for medical-legal evaluations?
Billing or charging for medical-legal evaluations, reports, or testimony in violation of the Medical-Legal Fee Schedule, specifically sections 9793-9795, constitutes a violation.
94
What constitutes providing false information in the context of QME appointments?
Providing false information on or with an application or reapplication for appointment as a QME.
95
What is required regarding expert opinions or conclusions in QME evaluations?
Failing to render expert opinions or conclusions without regard to an injured worker's race, sex, national origin, religion or sexual preference is a violation.
96
What actions are considered a violation of Labor Code Sections relevant to QMEs?
Participating in any activity that constitutes a violation of Labor Code Sections 4628, 139.3, or 139.31.
97
What happens if a QME violates section 41(a)(5) multiple times?
Having violated section 41(a)(5) on three or more occasions during the most recent period of appointment is a violation.
98
What is a violation related to performing a QME evaluation without valid certification?
Performing a QME evaluation or examination without valid QME certification at the time of examining the injured worker or signing the evaluation report.
99
What is considered an intentional act that can lead to disciplinary action for QMEs?
Participating in any intentional act that is not a necessary part of the physical examination that causes physical harm or injury to the injured worker.
100
What is the requirement for notifying the Administrative Director about a physician's license status?
Failure to notify the Administrative Director within 90 days that the physician's license to practice has been encumbered by suspension or probation is a violation.
101
What are the consequences of failing to comply with continuing education requirements according to section 55?
Failure to comply with the continuing education requirements may lead to grounds for suspending or terminating a Physician's privilege to participate in the workers' compensation system.
102
What procedures are in place for denial of reappointment?
Denial of reappointment is subject to the notice and appeal procedures outlined in sections 61 and 63.
103
What is defined as 'Face to Face time' in the context of evaluations?
'Face to face time' refers to the time the evaluator is physically present with an injured worker, including taking a history, performing a physical examination, or discussing the worker's condition.
104
What is excluded from the face-to-face time during a medical evaluation?
Time spent on research, records review, report writing, time with clinical or clerical staff, and time in waiting areas are excluded.
105
What must a QME include in the evaluation report for cardiovascular evaluations?
The evaluator must state the amount of face-to-face time actually spent and explain any variance below the minimum amount.
106
What is the minimum allowable face-to-face time for a QME evaluation concerning a claim for neuromusculoskeletal injury?
The minimum allowable face-to-face time is 20 minutes.
107
How should a QME report the face-to-face time spent with an injured worker for neuromusculoskeletal evaluations?
The evaluator shall state in the evaluation report the amount of face-to-face time actually spent and explain any variance below the minimum amount.
108
What is the minimum allowable face-to-face time for a QME evaluation concerning a claim for cardiovascular injury?
The minimum allowable face-to-face time is 30 minutes.
109
What should a QME report regarding the face-to-face time spent on pulmonary evaluations?
The evaluator shall state the amount of face-to-face time actually spent and explain any variance below the minimum amount.
110
What is the minimum allowable face-to-face time for QME evaluations concerning different types of injuries?
For pulmonary injury, the minimum is 30 minutes. For psychiatric injury, it is one hour. For other unspecified injuries, it is 30 minutes.
111
What must the evaluator include in the evaluation report regarding face-to-face time?
The evaluator must state the amount of face-to-face time actually spent with the injured worker and explain any variance below the minimum amount of face-to-face time.
112
How long are the terms for appointments of qualified medical evaluators as per Labor Code § 139.2?
The appointments shall be for two-year terms.
113
What additional requirement must a medical doctor or doctor of osteopathy fulfill to be appointed as a qualified medical evaluator?
They must be board certified in a specialty recognized by the administrative director or have successfully completed a residency training program accredited by the Accreditation Council for Graduate Medical Education or the osteopathic equivalent.
114
What is the requirement for physicians regarding the examination prior to appointment as a qualified medical evaluator?
Physicians must pass an examination written and administered by the administrative director to demonstrate competence in evaluating medical-legal issues in the workers' compensation system.
115
What qualifications must a physician meet to be appointed as a qualified medical evaluator according to the administrative director?
A physician must be licensed to practice in the state, pass a competence examination, complete a course on disability evaluation report writing, and devote at least one-third of total practice time to direct medical treatment or have served as an agreed medical evaluator on eight or more occasions in the prior 12 months.
116
How many hours of instruction must the disability evaluation report writing course include for physicians seeking appointment as qualified medical evaluators?
The course must include 12 or more hours of instruction.
117
What condition must a qualified medical evaluator meet regarding conflicts of interest?
They must not have a conflict of interest as determined under the regulations adopted by the administrative director.
118
What are the requirements for a psychologist to qualify as a qualified medical evaluator?
They must be board certified in clinical psychology, hold a doctoral degree in psychology with five years of postdoctoral experience, or have five years of postdoctoral experience and served as an agreed medical evaluator on eight or more occasions prior to January 1, 1990.
119
What is one requirement for a doctor of chiropractic to be certified in California workers' compensation evaluation?
They must be certified by a provider recognized by the administrative director, which includes instruction on disability evaluation report writing that meets specific standards.
120
What qualifications must a qualified medical evaluator have to be recognized by the administrative director and either the Medical Board of California or the Osteopathic Medical Board of California?
The qualifications must be deemed equivalent to board certification in a specialty.
121
What must a qualified medical evaluator do if their report is rejected by a workers' compensation administrative law judge?
The judge must make a specific finding regarding the rejection, and notice must be given to the medical evaluator and the administrative director.
122
What additional standards may the administrative director adopt for the appointment of physicians as qualified medical evaluators?
The administrative director may adopt standards for the appointment of physicians who are retired or hold teaching positions and are exceptionally well qualified, even if they do not qualify under specific criteria.
123
What is the maximum number of evaluations that can be rejected by a workers' compensation administrative law judge for a physician to remain eligible for reappointment as a qualified medical evaluator?
A physician can have no more than five evaluations rejected by a workers' compensation administrative law judge during the most recent two-year period.
124
How many hours of continuing education must a qualified medical evaluator complete within the previous 24 months to be eligible for reappointment?
A qualified medical evaluator must complete at least 12 hours of continuing education in impairment evaluation or workers' compensation-related medical dispute evaluation.
125
Under what circumstances can the administrative director suspend or terminate a qualified medical evaluator without a hearing?
The administrative director can suspend or terminate a qualified medical evaluator if their license to practice in California has been suspended, revoked, or terminated, or if they fail to timely pay the required fee.
126
What must the administrative director provide to a physician upon request after terminating or denying appointment as a qualified medical evaluator?
The administrative director must furnish a written statement of the reasons for termination or denial of appointment or reappointment.
127
What agreements will the administrative director establish with qualified medical evaluators?
The administrative director will establish agreements to ensure the expeditious evaluation of cases assigned to qualified medical evaluators for comprehensive medical evaluations.
128
What conditions must a qualified medical evaluator meet to avoid reappointment denial by the administrative director?
The evaluator must not have been terminated, suspended, placed on probation, or otherwise disciplined during their most recent term as a qualified medical evaluator.
129
What criteria must a qualified medical evaluator meet to be included in the list for random selection?
The evaluator must not have a conflict of interest in the case and must be certified by the administrative director to evaluate in an appropriate specialty.
130
What information must the form provided to the employee include regarding the physicians selected for their panel?
The form must include the physician's name, address, telephone number, specialty, number of years in practice, and a brief description of his or her education and training.
131
What rights does the employee have regarding consultation before selecting the doctor for their evaluation?
The employee has the right to consult with an information and assistance officer at no cost or with an attorney prior to selecting the doctor.
132
What happens if a panel is not assigned within 20 working days?
The employee shall have the right to obtain a medical evaluation from any qualified medical evaluator of his or her choice within a reasonable geographic area.
133
What does the medical director review regarding comprehensive medical evaluations and reports?
The medical director reviews the quality of evaluations and reports, including a random sample of reports and all reports alleged to be inaccurate or incomplete.
134
What happens if there are not enough qualified medical evaluators of a specific type within the employee's geographic area?
The medical director shall include sufficient qualified medical evaluators from other geographic areas, and the employer shall pay all necessary travel costs incurred if the employee selects an evaluator from another geographic area.
135
What is the timeframe for initial medical evaluations to be prepared and submitted by qualified medical evaluators?
The timeframe shall be no more than 30 days after the evaluator has seen the employee or otherwise commenced the medical evaluation.
136
How many locations can a qualified medical evaluator conduct evaluations at?
A qualified medical evaluator shall not conduct evaluations at more than 10 locations.
137
What are the two cases in which the 30-day evaluation period can be extended?
The 30-day evaluation period can be extended when the evaluator has not received test results or consulting physician's evaluations in time, and to extend the period by not more than 15 days for good cause.
138
What constitutes 'good cause' for extending the 30-day evaluation period?
'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 business.
139
What regulations will the administrative director develop regarding qualified medical evaluators?
The administrative director will develop timeframes governing the availability of qualified medical evaluators for unrepresented employees under Section 4062.1.
140
What procedures must physicians follow in evaluating permanent impairment and limitations resulting from an injury?
Physicians must follow procedures consistent with Sections 4660 and 4660.1.
141
What right does an employee have regarding the timing of their evaluation by a physician?
The employee has the right to be seen by the physician within a specified period of time, but can waive this right for a specified period thereafter.
142
What is required for the diagnosis of a psychiatric injury?
The diagnosis of a mental disorder must be expressed using the terminology and criteria of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders or other nationally accepted psychiatric diagnostic manuals.
143
Which section governs the determination of disputed medical treatment issues?
Section 5307.27 governs the determination of disputed medical treatment issues.
144
What guidelines are established for medical-legal evaluations that have not been defined and valued?
Guidelines shall establish minimum times for patient contact in the conduct of the evaluations, consistent with regulations adopted pursuant to Section 5307.6.
145
What can lead to the suspension or termination of a physician's privilege to serve as a qualified medical evaluator?
A physician can be suspended or terminated for violating statutory duties, failing to follow established medical procedures, not complying with timeframe standards, not meeting specific requirements, preparing substandard medical-legal evaluations, or making false statements in their application.
146
What is the consequence for a physician who is suspended or placed on probation by the relevant licensing board?
They shall be suspended or terminated as a medical evaluator.
147
What actions can the administrative director take upon finding a violation listed in subdivision (k)?
The administrative director can terminate or suspend the qualified medical evaluator, or place them on probation with appropriate conditions.
148
What must happen to a qualified medical evaluator whose licensure has been terminated by the relevant licensing board?
They shall be terminated from the list of medical evaluators.
149
What happens to a report prepared by a physician who is suspended or terminated as a qualified medical evaluator?
The report shall not be admissible in any proceeding before the appeals board, and there shall be no liability for payment for the report.
150
What is the time frame for setting a hearing on an alleged violation after a citation is served on a qualified medical evaluator?
The hearing must be set within 30 days of service of the citation.
151
What is prohibited for an evaluator regarding compensation or value from external sources?
An evaluator shall not request or accept any compensation or other thing of value from any source that does or could create a conflict with his or her duties as an evaluator under this code.
152
What does Section 4060(a) state about disputes over compensability of injuries?
This section shall apply to disputes over the compensability of any injury and shall not apply where injury to any part or parts of the body is accepted as compensable by the employer.
153
What procedure must be followed for a medical evaluation to determine compensability if the employee is represented by an attorney?
A medical evaluation to determine compensability shall be obtained only by the procedure provided in Section 4062.2.
154
Who is not liable for a comprehensive medical-legal evaluation performed by someone other than the treating physician?
Neither the employer nor the employee shall be liable for any comprehensive medical-legal evaluation performed by other than the treating physician, except as provided in this section.
155
What language must be included in the notice regarding attorney representation?
The notice must include language advising that the decision to be represented by an attorney is voluntary, may not be necessary for receiving benefits, and that the attorney's fee will be deducted from any award for disability benefits.
156
What should each notice required by subdivision (d) describe?
Each notice should describe the administrative procedures available to the injured employee and advise them of their right to consult an information and assistance officer or an attorney.
157
Who can request a comprehensive medical evaluation to determine compensability?
Either party, the employer or the employee, may request a comprehensive medical evaluation to determine compensability.
158
What must accompany the notice required by subdivision (d)?
The notice must be accompanied by the form prescribed by the administrative director for requesting the assignment of a panel of qualified medical evaluators.
159
What must an employer provide to an employee not represented by an attorney regarding a comprehensive medical evaluation?
The employer must provide notice that either they request a comprehensive medical evaluation to determine compensability or that they have not accepted liability and the employee may request such an evaluation.
160
What should the notice state if the amount of permanent disability indemnity cannot be determined?
The notice should state that permanent disability indemnity may be or is payable, but the amount cannot be determined because the employee's medical condition is not yet permanent and stationary.
161
What information must be included in the notice regarding permanent disability indemnity?
The notice must include information on how the employee may obtain a formal medical evaluation if they disagree with the employer's position, and if applicable, the amount of permanent disability indemnity determined payable and the basis for that determination.
162
What must the employer provide to the employee along with the last payment of temporary disability indemnity?
The employer must provide either notice that no permanent disability indemnity will be paid or notice of the amount of permanent disability indemnity determined to be payable, along with information on obtaining a formal medical evaluation if the employee disagrees.
163
What should the notice indicate if the employer determines that permanent disability indemnity is payable?
The notice should advise the employee of the amount determined payable, the basis for that determination, and whether there is a need for continuing medical care.
164
What information must each notice to the injured employee include?
Each notice must describe the administrative procedures available to the injured employee and advise them of their right to consult an information and assistance officer or an attorney.
165
What must an employer do within 14 days if they change their position regarding an employee's permanent impairment?
The employer must provide the employee with the notice specified in paragraph (1) within 14 days of the determination to take either position.
166
What is the purpose of the evaluation performed to determine permanent impairment and limitations?
The evaluation determines the existence and extent of permanent impairment and limitations for the purpose of rating permanent disability and to assess the need for continuing medical care.
167
What does the notice advise regarding representation by an attorney?
The notice advises that if the employee decides to be represented by an attorney, they may or may not receive a larger award, but the attorney's fee will be deducted from any award for disability benefits unless they are determined to be ineligible.
168
What must an employer provide to an unrepresented employee if there is no agreement on a permanent disability rating based on the treating physician's evaluation?
The employer shall immediately provide the employee with a form prescribed by the medical director to request assignment of a panel of three qualified medical evaluators.
169
Who may request a comprehensive medical evaluation to determine permanent disability?
Either party may request a comprehensive medical evaluation to determine permanent disability.
170
What is the process for obtaining a permanent disability evaluation if the parties do not agree on the treating physician's evaluation and the employee is represented by an attorney?
A medical evaluation to determine permanent disability shall be obtained as provided in Section 4062.2.
171
What is the timeline for the administrative director to calculate the permanent disability rating after receiving the comprehensive medical evaluation?
Within 20 days of receipt of the comprehensive medical evaluation, the administrative director shall calculate the permanent disability rating.
172
What must a written request for reconsideration of a rating include?
It must specify the reasons the rating should be reconsidered and be served on the other party.
173
What can an unrepresented employee or employer do within 30 days of receiving a rating?
They may request that the administrative director reconsider the recommended rating or obtain additional information from the treating physician or medical evaluator.
174
What action does the administrative director take if the comprehensive medical evaluation is found to be incomplete or not compliant?
The administrative director shall return the report to the treating physician or qualified medical evaluator for appropriate action as instructed.
175
What must be done if a comprehensive medical evaluation for an unrepresented employee indicates potential apportionment of permanent impairment?
The evaluation must be submitted by the administrative director to a workers' compensation judge, who may refer the report back for correction or clarification if the proposed apportionment is inconsistent with the law.
176
What actions must an employer take if a comprehensive medical evaluation requires compensation?
The employer shall commence the payment of compensation or promptly commence proceedings before the appeals board to resolve the dispute.
177
What does the appeals board need to determine regarding stipulated findings and awards or commutation of the award?
The appeals board shall first determine whether the agreement or commutation is in the best interests of the employee and whether the proper procedures have been followed in determining the permanent disability rating.
178
What must the administrative director provide to the employee at the time of service of any rating?
The administrative director shall promulgate a form to notify the employee of the options specified, the potential advantages and disadvantages of each option, and the procedure for disputing the rating.
179
What must the administrative director do with the permanent disability rating according to Section 4660?
The administrative director shall recalculate the permanent disability rating and serve the rating, the comprehensive medical evaluation, and the summary form on the employee and employer.
180
What should be prepared if there is more than one treating physician managing an injured worker's care?
A single report shall be prepared by the physician primarily responsible for managing the injured worker's care that incorporates the findings of the various treating physicians.
181
Who is responsible for rendering opinions on all medical issues necessary to determine eligibility for compensation?
The treating physician primarily responsible for managing the care of the injured worker or the physician designated by that treating physician.
182
What is required before a declaration of readiness to proceed can be made regarding permanent impairment and limitations from an injury?
There must first be a medical evaluation by a treating physician or an agreed or qualified medical evaluator.
183
What happens to evaluations obtained in violation of the prohibition on permanent impairment assessments?
Evaluations obtained in violation of this prohibition shall not be admissible in any proceeding before the appeals board.
184
Can the time limits for notifying objections be extended?
Yes, these time limits may be extended for good cause or by mutual agreement.
185
What is the time limit for an employee to notify the employer of an objection to a decision made pursuant to Section 4610?
The employee shall notify the employer of the objection in writing within 20 days of receipt of that decision.
186
What must be obtained if the employee is represented by an attorney and there is a disputed medical issue?
A medical evaluation to determine the disputed medical issue shall be obtained as provided in Section 4062.2.
187
What is the time limit for an objecting party to notify the other party of an objection to a treating physician's determination if the employee is represented by an attorney?
The objecting party must notify the other party in writing within 20 days of receipt of the report.
188
What is the time frame for an employer to object to a treating physician's report recommending spinal surgery?
The employer may object within 10 days of receipt of the report.
189
What must the employer do if the second opinion report recommends surgery?
The employer shall authorize the surgery.
190
What happens if the employee is represented by an attorney and there is a disagreement on the second opinion report?
The parties shall seek agreement on a California licensed board-certified or board-eligible orthopedic surgeon or neurosurgeon to prepare the second opinion report.
191
What is the employer's liability regarding medical treatment costs for a disputed surgical procedure performed before the completion of the second opinion process?
The employer shall not be liable for medical treatment costs for the disputed surgical procedure or for periods of temporary disability resulting from the surgery.
192
What is the process if no agreement is reached on a second opinion report within 10 days?
An orthopedic surgeon or neurosurgeon shall be randomly selected by the administrative director to prepare the second opinion report.
193
What affiliations must a second opinion physician avoid according to the administrative director?
A second opinion physician must not have any material professional, familial, or financial affiliation with the employer, the employer's workers' compensation insurer, third-party claims administrator, health care provider, or any related entities.
194
What is prohibited if an employee is not represented by an attorney in the context of medical evaluations?
If an employee is not represented by an attorney, the employer shall not seek agreement with the employee on an agreed medical evaluator, nor shall an agreed medical evaluator prepare the formal medical evaluation on any issues in dispute.
195
Who is responsible for scheduling the appointment for the medical evaluation if the employee has not made the appointment?
If the employee has not made the appointment, the employer shall arrange the appointment.
196
What is the time frame for an employee to submit a form for a medical evaluation after receiving it from the employer?
The employee must submit the form within 10 days after the employer has furnished the form.
197
What happens if the employee does not inform the employer of their selection of a physician within 10 days?
If the employee does not inform the employer within 10 days, the employer may select the physician from the panel to prepare a medical evaluation.
198
What must the party submitting the request form for a medical evaluation designate?
The party must designate the specialty of the physicians that will be assigned to the panel.
199
What happens if an unrepresented employee declines to proceed with the evaluation?
The employee has the right to a new panel of three qualified medical evaluators to select one for a comprehensive medical evaluation.
200
What opportunity must the evaluator give the employee at the appointment?
The evaluator shall give the employee a brief opportunity to ask questions concerning the evaluation process and the evaluator's background.
201
What are the consequences if the appeals board determines that the employee did not have good cause to not proceed with the evaluation?
The cost of the evaluation shall be deducted from any award the employee obtains.
202
Under what circumstances can an unrepresented employee discontinue the evaluation?
An employee can discontinue the evaluation if there is good cause, such as evidence of bias from the evaluator or unnecessary medical examinations.
203
What must the employer provide upon notifying the employee of an appointment for evaluation?
The employer shall furnish payment of estimated travel expense.
204
What is required to resolve disputes arising from injuries occurring on or after January 1, 2005?
A comprehensive medical evaluation is required.
205
Who can commence the selection process for an agreed medical evaluator?
Either party may commence the selection process by making a written request naming at least one proposed physician.
206
What must the parties do if they cannot agree on a medical evaluator within 10 days?
Either party may request the assignment of a three-member panel of qualified medical evaluators.
207
What happens if an employee is represented by an attorney regarding additional evaluations?
The employee shall not be entitled to an additional evaluation.
208
Is an employee entitled to an additional medical-legal evaluation if they cease to be represented after receiving one?
No, if an employee has received a comprehensive medical-legal evaluation and later ceases to be represented, they shall not be entitled to an additional evaluation.
209
Who is responsible for arranging the appointment for the medical examination?
The represented employee is responsible for arranging the appointment for the examination.
210
What happens if the parties do not agree on a medical evaluator within the specified timeframe?
If the parties have not agreed on a medical evaluator from the panel by the 10th day after assignment, each party may strike one name from the panel.
211
What is the consequence if a party fails to exercise the right to strike a name from the panel within three working days?
If a party fails to strike a name within three working days, the other party may select any physician who remains on the panel to serve as the medical evaluator.
212
What is the timeframe for parties to agree on a medical evaluator after the assignment of the panel?
The parties shall confer and attempt to agree upon an agreed medical evaluator within 10 days of assignment of the panel.
213
What happens if the employee fails to inform the employer of the appointment within 10 days after the medical evaluator has been selected?
If the employee fails to inform the employer within 10 days, the employer may arrange the appointment and notify the employee of the arrangements.
214
What must the agreed or qualified medical evaluator identify in a formal medical evaluation?
All information received from the parties, all information reviewed in preparation of the report, and all information relied upon in the formulation of their opinion.
215
What records can be provided to a qualified medical evaluator selected from a panel?
Records prepared or maintained by the employee's treating physician, and medical and nonmedical records relevant to the determination of the medical issue.
216
How many days in advance must information be served on the opposing party before being provided to the evaluator?
20 days.
217
What is required for communications with a medical evaluator before a medical evaluation?
All communications must be in writing and served on the opposing party 20 days in advance of the evaluation.
218
What happens if the opposing party objects to the consideration of nonmedical records?
If the opposing party objects within 10 days thereafter, the records shall not be provided to the evaluator.
219
What must the medical evaluator do upon completing a determination of the disputed medical issue?
The medical evaluator shall summarize the medical findings on a form.
220
Are there any exceptions to the communication rules during the examination?
Subdivisions (e) and (f) do not apply to oral or written communications by the employee or the employee's dependent at the request of the evaluator during the examination.
221
What can an aggrieved party do if a party communicates with the medical evaluator in violation of the rules?
The aggrieved party may elect to terminate the medical evaluation and seek a new evaluation from another qualified medical evaluator or proceed with the initial evaluation.
222
What are the consequences for a party that communicates in violation of the communication rules?
The party shall be subject to being charged with contempt before the appeals board and shall be liable for the costs incurred by the aggrieved party as a result of the prohibited communication.
223
What is prohibited regarding communication with an agreed medical evaluator or a qualified medical evaluator?
Ex parte communication is prohibited.
224
What is required before a disputed medical issue can be the subject of a declaration of readiness to proceed?
There must first be an evaluation by the treating physician or an agreed or qualified medical evaluator.
225
What must the medical evaluation address according to the administrative director's requirements?
The medical evaluation must address all contested medical issues arising from all injuries reported on one or more claim forms prior to the date of the employee's initial appointment with the medical evaluator.
226
What happens if a qualified medical evaluator fails to complete the formal medical evaluation within the established timeframes?
A new evaluation may be obtained upon the request of either party, as provided in Sections 4062.1 or 4062.2.
227
What should parties do if there is an objection to a new medical issue after a medical evaluation?
The parties should utilize the same medical evaluator who prepared the previous evaluation to resolve the medical dispute, to the extent possible.
228
Who is liable for payment for a formal medical evaluation that was not completed within the required timeframes?
Neither the employee nor the employer shall have any liability for payment for the formal medical evaluation which was not completed within the required timeframes unless the employee or employer caused the delay.
229
What must the employer do if a formal medical evaluation requires them to provide compensation?
The employer shall commence the payment of compensation or file an application for adjudication of claim.
230
What is the liability of the employer regarding comprehensive medical-legal evaluations obtained by the employee?
The employer shall be liable for the cost of each reasonable and necessary comprehensive medical-legal evaluation obtained by the employee.
231
Are employers liable for the cost of comprehensive medical evaluations obtained by the employee?
The employer shall not be liable for the cost of any comprehensive medical evaluations obtained by the employee other than those authorized pursuant to Sections 4060, 4061, and 4062.
232
What reports is an employee entitled to after Section 4062 is completed?
The employee shall be entitled to the same reports at employer expense as an employee who has been represented from the time the dispute arose, and those reports shall be admissible in any proceeding before the appeals board.
233
Can parties obtain medical evaluations or consultations at their own expense?
Yes, no party is prohibited from obtaining any medical evaluation or consultation at the party's own expense.
234
What happens to the admissibility of comprehensive medical evaluations obtained by any party?
All comprehensive medical evaluations obtained by any party shall be admissible in any proceeding before the appeals board except as provided in specific subdivisions of Sections 4061 and 4062.
235
What happens if the agreed medical evaluator has previously evaluated the same or similar issues?
The subsequent formal medical evaluation shall be conducted by the same agreed medical evaluator or qualified medical evaluator.
236
When can a different medical evaluator be selected for a formal medical evaluation?
A different medical evaluator can be selected if the workers' compensation judge finds that the prior evaluator's formal medical evaluation was not relied upon, if any party contested the original evaluation, if the unrepresented employee hired an attorney and selected a new evaluator, or if the prior evaluator is no longer qualified or available.
237
Who assesses the employee's attorney's fees against the employer in a workers' compensation case?
The workers' compensation judge or the appeals board assesses the employee's attorney's fees against the employer.
238
What must be obtained if the jurisdiction of the appeals board is invoked due to changes in the effects of an injury?
A formal medical evaluation must be obtained.
239
What happens if the employer neglects or refuses to provide necessary medical treatment?
The employer is liable for the reasonable expense incurred by or on behalf of the employee in providing treatment.
240
What types of treatment must be provided by the employer to an injured worker?
The employer must provide medical, surgical, chiropractic, acupuncture, and other necessary treatments to cure or relieve the effects of the worker's injury.
241
What actions can the administrative director take if a treating physician's reports show a pattern of unsupported opinions?
The administrative director shall notify the physician's applicable licensing body in writing.
242
What should the appeals board do if a treating physician's report contains unsupported opinions?
The appeals board shall notify the administrative director in writing.
243
What rights does an employee have regarding treatment after 30 days from the date the injury is reported?
The employee may be treated by a physician of their own choice or at a facility of their own choice within a reasonable geographic area.
244
What must an employee do to be treated by their personal physician from the date of injury?
The employee must notify their employer in writing prior to the date of injury that they have a personal physician and have health care coverage for nonoccupational injuries on the date of injury.
245
What defines medical treatment that is reasonably required for an injured worker?
It means treatment based on evidence-based guidelines, including the Medical Treatment Utilization Schedule, adopted by the administrative director pursuant to Section 5307.27.
246
What may an insurer require before nonemergency treatment or diagnostic services?
The insurer may require prior authorization for any nonemergency treatment or diagnostic service.
247
What entitlements does an employee have regarding referrals by their personal physician?
An employee is entitled to all medically appropriate referrals by the personal physician to other physicians or medical providers within the nonoccupational health care plan.
248
What may an insurer require for nonemergency treatment or diagnostic services?
The insurer may require prior authorization and may conduct reasonably necessary utilization review.
249
What are the conditions that a personal physician must meet according to the regulations?
A personal physician must be the employee's regular physician, be the primary care physician who has directed the employee's medical treatment and retains their medical records, and agree to be predesignated.
250
What expenses are covered for an employee reporting for a medical examination?
Reasonable expenses of transportation, meals, lodging, and one day of temporary disability indemnity for each day of wages lost.
251
Who is responsible for providing a qualified interpreter for an employee who does not proficiently speak or understand English during a medical examination?
The employer is responsible for providing the services of a qualified interpreter.
252
What is the mileage reimbursement rate for transportation to a medical examination?
The mileage reimbursement rate is twenty-one cents ($0.21) a mile or the mileage rate adopted by the Director of Human Resources, whichever is higher, plus any bridge tolls.
253
When is an employer not liable for home health care services?
The employer is not liable for home health care services provided more than 14 days prior to the receipt of the physician's prescription.
254
Under what conditions are home health care services covered as medical treatment?
Home health care services are covered if reasonably required to cure or relieve the employee from the effects of their injury and prescribed by a licensed physician.
255
What are the requirements for an interpreter during medical treatment appointments?
An interpreter is not required to meet the same certification requirements as for examinations but must meet any similar requirements established by the administrative director.
256
What defines a 'qualified interpreter' in the context of workers' compensation?
A qualified interpreter is a language interpreter certified or deemed certified according to specific sections of the Government Code.
257
What should be included in the medical-legal report if there is a variance from the established guidelines?
The report must explain in detail any variance and the reasons for it.
258
What happens if a physician fails to comply with the requirements for producing a medical-legal report?
The report becomes inadmissible as evidence and eliminates any liability for payment of medical-legal expenses incurred in connection with the report.
259
What may happen to a physician assessed a civil penalty under the medical-legal report compliance section?
The physician may be terminated, suspended, or placed on probation as a qualified medical evaluator.
260
What does 'medically necessary' mean according to the document?
'Medically necessary' means medical treatment that is reasonably required to cure or relieve the injured employee of the effects of their injury, based on specific standards including guidelines, peer-reviewed evidence, professional standards, and expert opinion.
261
How is 'disputed medical treatment' defined in this context?
'Disputed medical treatment' means medical treatment that has been modified or denied by a utilization review decision on the basis of medical necessity.
262
What types of disputes does Section 4610.5 apply to?
It applies to disputes over a utilization review decision regarding treatment for injuries occurring on or after January 1, 2013, disputes communicated to the requesting physician on or after July 1, 2013, and disputes over medication prescribed pursuant to the drug formulary adopted after January 1, 2018.
263
Who is considered an 'employer' in the context of utilization review?
The term 'employer' includes the employer, the insurer of an insured employer, a claims administrator, or a utilization review organization, or other entities acting on behalf of any of them.
264
What does the one-page form provided to the employee include?
The form includes notice that the utilization review decision is final unless the employee requests independent medical review, a statement for the employee's consent to obtain necessary medical records, and notice of the employee’s right to provide information or documentation.
265
What must an employer provide to an employee when a utilization review decision denies or modifies a treatment recommendation?
The employer must provide a one-page form prescribed by the administrative director and an addressed envelope for the employee to initiate an independent medical review.
266
What can an employee do if a utilization review decision denies or modifies a treatment recommendation?
The employee may request an independent medical review as provided by the relevant section.
267
What is a utilization review decision?
A utilization review decision is a decision to modify or deny a treatment recommendation based on medical necessity, occurring prior to, retrospectively, or concurrently with the provision of medical treatment services.
268
What happens if the employer fails to comply with notification requirements at the time of the utilization review decision?
If the employer fails to comply with the notification requirements, the time limitations for the employee to submit a request for independent medical review shall not begin to run until the employer provides the required notice to the employee.
269
What must the treating physician's recommendation indicate regarding disputed medical treatment?
The treating physician's recommendation must indicate that the disputed medical treatment is medically necessary for the employee's medical condition.
270
Who can submit a request for independent medical review in cases of emergency medical treatment?
A provider of emergency medical treatment, when the employee faced an imminent and serious threat to health, may submit a request for independent medical review on its own behalf.
271
What type of medical information can support an employee's position in a disputed medical treatment case?
Reasonable information supporting the employee's position can include all information provided to the employee by the employer or the treating physician concerning the disputed medical treatment, as well as any additional material the employee believes is relevant.
272
What is the time frame for an employee to submit a request for independent medical review for formulary disputes?
The request for independent medical review for formulary disputes must be made no later than 10 days after the service of the utilization review decision to the employee.
273
Under what condition can the independent medical review process be terminated?
The independent medical review process may be terminated at any time upon the employer's written authorization of the disputed medical treatment.
274
What must the employer provide to the independent medical review organization upon notice of assignment?
The employer must electronically provide a copy and list of all relevant medical records, information provided to the employee concerning decisions regarding the disputed treatment, and any materials submitted by the employee or their provider in support of the request.
275
What is the role of the administrative director in the independent medical review process?
The administrative director or their designee shall expeditiously review requests and notify the employee and employer in writing about the approval status of the independent medical review request.
276
What happens if there is a medical necessity issue during the independent medical review process?
The dispute shall be resolved pursuant to an independent medical review, unless the employer disputes liability for the treatment for reasons other than medical necessity.
277
Who can an employee designate to act on their behalf in the independent medical review process?
An employee may designate a parent, guardian, conservator, relative, or other designee as an agent to act on their behalf.
278
What is the penalty for an employer who delays the independent medical review process?
The employer shall be subject to an administrative penalty not to exceed five thousand dollars ($5,000) for each day that proper notification to the employee is delayed.
279
What notification must the employer issue to the employee after submitting all required material to the independent medical review organization?
The employer must issue a notification that lists the documents submitted and includes copies of material not previously provided to the employee or the employee’s designee.
280
What is the time frame for delivering necessary information to the independent medical review organization if there is an imminent and serious threat to the health of the employee?
All necessary information and documents must be delivered to the independent medical review organization within 24 hours of approval of the request for review.
281
What documents must the employer provide to the employee and the requesting physician regarding the denial or modification of treatment based on medical necessity?
The employer must provide a copy of any relevant documents or information used in determining whether the disputed treatment should have been provided, along with any statements explaining the reasons for the decision.
282
What should the employer do with newly developed or discovered relevant medical records after the initial documents are provided to the independent medical review organization?
The employer shall forward the newly developed or discovered relevant medical records immediately to the independent medical review organization and provide a copy to the employee or the employee’s treating physician.
283
What is the responsibility of the claims administrator regarding changes in the claims administrator responsible for a claim?
The claims administrator who issued the utilization review decision in dispute must notify the independent medical review organization of any change in the claims administrator within five working days of the change taking effect.
284
What was the role of the QME in the Escobedo case?
The QME (Dr. Ovadia) apportioned 50% of her permanent disability to the preexisting arthritis.
285
What injury did Marlene Escobedo sustain while working at Marshalls?
Marlene Escobedo sustained an industrial injury to her left knee on October 28, 2002.
286
According to the Escobedo case, what must apportionment under section 4663 be based on?
Apportionment under section 4663 must be based on causation of permanent disability, not causation of injury.
287
What criteria must medical evidence meet to constitute substantial evidence on apportionment?
Medical evidence must be based on reasonable medical probability, not be speculative, be based on pertinent facts and adequate examination, and explain the reasoning behind conclusions.
288
What is the significance of the Escobedo case in relation to apportionment of permanent disability?
The Escobedo case established key principles for apportionment of permanent disability under Labor Code section 4663 following the 2004 SB 899 reforms.
289
What must a reporting physician determine regarding permanent disability apportionment?
A reporting physician must determine what percentage of disability was directly caused by the industrial injury and what percentage was caused by other factors, including pathology and asymptomatic conditions.
290
What is the burden of proof regarding the percentage of disability caused by an industrial injury?
The employee must prove the percentage of disability directly caused by the industrial injury, while the employer must prove the percentage caused by other factors.
291
What factors contributed to the WCAB upholding the WCJ's 50% apportionment in the discussed case?
The WCAB upheld the 50% apportionment because Dr. Ovadia's report was based on adequate examination and facts, explained his reasoning, stated opinions to reasonable medical probability, properly assessed causation percentages, and adequately explained the basis for the 50% apportionment to preexisting arthritis.
292
How did Dr. Cheng assess the impairments in the Kite case?
Dr. Cheng chose to combine the impairments through simple addition rather than using the Combined Values Chart.
293
What triggers increased permanent disability benefits in relation to a late return-to-work offer?
An employee who returns to work before permanent and stationary (P&S) status is still entitled to a 15% permanent disability increase if no timely offer is made within 60 days of P&S status.
294
What is the method for combining bilateral hip impairments according to the case?
Doctors have discretion to choose the appropriate combination method, and Dr. Cheng's use of simple addition was deemed proper due to the synergistic effect of bilateral hip injuries.
295
What was the outcome of the court's decision regarding the Workers' Compensation Appeals Board's ruling?
The court annulled the Workers' Compensation Appeals Board's decision and directed them to accept Dr. Kaye's apportionment.
296
What injury did Aaron Lindh sustain during his canine training course?
Aaron Lindh sustained an injury to his left eye.
297
What significant change did California's 2004 workers' compensation law introduce regarding apportionment?
The law now allows consideration of pre-existing conditions and pathology when determining disability percentages.
298
What percentage of Aaron Lindh's disability was attributed to his pre-existing condition according to Dr. Kaye?
Dr. Kaye concluded that 85% of Lindh's disability was due to his pre-existing condition.
299
Why is the case of City of Petaluma et al. v. Workers' Compensation Appeals Board significant?
It confirms that under current California law, asymptomatic pre-existing conditions can be considered when apportioning permanent disability.
300
What four-step analysis process was established by the WCAB for psychiatric injury cases in Rolda v. Pitney Bowes, Inc.?
The four-step analysis process includes determining whether actual employment events occurred, if those events were the predominant cause, if the actions were lawful and nondiscriminatory, and if good faith personnel actions were a substantial cause.
