QME Trove Flashcards
What was a significant reason workers’ compensation systems were established in the early twentieth century in the U.S.?
To prevent the need for employees to prove employer negligence in court
What was the primary purpose of the Boynton Act of 1913?
To require most employers to provide workers’ compensation coverage
Which act replaced the Boynton Act in 1917 and included provisions for considering an employee’s diminished ability to compete in the labor market?
The Workers’ Compensation Insurance and Safety Act
What does the “No Fault” rule in the workers’ compensation system imply?
Employers are required to provide benefits regardless of who caused the injury, Employees cannot file for workers’ compensation if they were aware of the risks
Under the “Historic Compromise,” what is one benefit that employees give up in exchange for prompt workers’ compensation benefits?
The right to file a civil suit for damages
Which of the following is NOT a component of the “Historic Compromise” in the workers’ compensation system?
Unlimited Compensation
What happens to workers’ compensation benefits if an injury results from the serious and willful misconduct of the employer?
Benefits are doubled
What changes were introduced by the measures enacted in 2003 and 2004 regarding medical treatment?
Allowed employers to establish medical provider networks and limit certain treatments
Which of the following is an exception to the “No Fault” rule under California workers’ compensation law?
Deliberately self-inflicted injuries
What was one of the major changes introduced in 2013 to California’s workers’ compensation system?
Introduction of independent medical review for treatment disputes, Elimination of medical provider networks, Reducing the amount of compensation for temporary disabilities
Which of the following individuals is NOT associated with the Department of Industrial Relations?
Jose Garcia,
What is the primary mission of the Division of Workers’ Compensation (DWC)?
To minimize the adverse impact of work-related injuries on California employees and employers,
Which unit within the DWC is responsible for conducting audits to ensure compliance with the Labor Code and DWC regulations?
Audit and Enforcement Unit,
What does the Disability Evaluation Unit (DEU) primarily determine?
Permanent disability ratings,
Which unit provides assistance to employees, employers, and other parties regarding rights and benefits under California’s workers’ compensation laws?
Information and Assistance (I&A) Unit,
What is one function of the Workers’ Compensation Appeals Board (WCAB)?
Reviewing Petitions for Reconsideration of decisions made by Workers’ Compensation Administrative Law Judges,
Which unit is responsible for overseeing medical provider networks and handling complaints against Qualified Medical Evaluators (QMEs)?
Medical Unit,
What is the purpose of the Workers’ Compensation Information System (WCIS)?
To collect and manage electronic records from claims administrators,
Which fund provides compensation when employers fail to pay workers’ compensation benefits and are illegally uninsured?
Uninsured Employers Benefits Trust Fund (UEBTF),
What type of permanent disability ratings does the DEU prepare?
Formal, consultative, and summary,
The Medical Unit under the DWC is involved in which of the following activities?
Certifying and overseeing medical provider networks (MPNs),
Which unit is tasked with assisting in the resolution of disputes and complaints related to workers’ compensation claims?
Information and Assistance (I&A) Unit,
Which fund provides additional compensation to workers who had a pre-existing disability that combined with a new injury to result in a permanent disability of at least 70%?
Subsequent Injuries Benefits Trust Fund (SIBTF)
What role does the Audit and Enforcement Unit play in the workers’ compensation system?
It ensures that insurance companies and self-insured employers meet their obligations under the Labor Code,
Which unit is responsible for examining and appointing physicians to be Qualified Medical Evaluators (QMEs)?
Medical Unit,
What is the main function of the Legal Unit within the DWC?
To provide legal advice and representation for the DWC,
Which of the following is a responsibility of the Disability Evaluation Unit (DEU)?
Preparing permanent disability ratings for use in determining benefits
The Workers’ Compensation Appeals Board (WCAB) consists of how many commissioners?
Seven
Which unit handles disputes and complaints related to the Qualified Medical Evaluator (QME) process?
Medical Unit
What is the primary function of the Research Unit within the DWC?
To analyze and report on data related to the workers’ compensation system
Which unit is responsible for assisting injured workers with understanding their rights and benefits under California’s workers’ compensation laws?
Information and Assistance (I&A) Unit
What is the purpose of taking a complete occupational history?
To understand all jobs the worker has held, including hazards and protective equipment used
How is a specific injury defined in the context of workers’ compensation?
An injury resulting from a single incident or exposure
What is the definition of first aid according to the Labor Code?
Any one-time treatment for minor injuries that do not require further medical care
What does the term “arising out of employment” (AOE) refer to?
The injury is directly related to the work environment or tasks
What is considered an aggravation of a pre-existing non-industrial condition?
An on-the-job incident that worsens a pre-existing condition
In the workers’ compensation system, which of the following injuries is excluded from compensation?
Injuries resulting from alcohol or illegal substance use
When determining causation, which of the following is NOT a type of causation?
Recurrence
Why is the “date of injury” (DOI) important in a workers’ compensation claim?
It determines the statute of limitations for filing a claim
What is required to prove that an injury is work-related?
Work activities contributed to the injury to a significant degree
How is a cumulative injury defined in the context of workers’ compensation?
An injury that results from repetitive trauma over time
In which scenario would a physician’s report NOT lead to the establishment of a compensable injury?
The injury was caused by the employee’s use of illegal substances
What does “occurring in the course of employment” (COE) imply?
The injury occurred while the employee was performing job-related duties
Which of the following best describes the role of a physician in the workers’ compensation system?
Providing medical opinions that guide claims decisions
What should a physician consider when establishing causation for a cumulative injury?
The worker’s medical history and all relevant exposures
How are psychiatric injuries treated differently in workers’ compensation claims?
They require a higher standard of proof for causation
What is the purpose of taking a complete occupational history?
To understand all jobs the worker has held, including hazards and protective equipment used
How is an injury defined under the workers’ compensation system?
Any injury or disease arising out of employment
Which of the following is considered first aid according to Labor Code § 5401(a)?
One-time treatment for minor injuries like cuts and burns
What does “Aggravation” refer to in workers’ compensation terms?
A temporary or permanent increase in disability due to work
Which of the following best defines “Arising Out of Employment” (AOE)?
An injury directly caused by work activities
Which of the following is NOT necessary to establish when determining causation?
The workplace location
What is the significance of “Occurring in the Course of Employment” (COE) in workers’ compensation?
It involves the circumstances surrounding the accident or exposure
What is a “Presumption” in the context of workers’ compensation?
A legal assumption that certain conditions are work-related for specific employee groups
Under what condition is a psychiatric injury compensable according to Labor Code §3208.3?
If it is a diagnosed mental disorder with employment being the predominant cause
What happens if a psychiatric claim is filed after notice of termination or layoff?
It is not compensable unless specific conditions are met
Which of the following is an example of an “incidental” activity included in the course of employment?
Traveling on behalf of the employer
Which of the following best describes the role of a physician in determining AOE/COE?
To provide medical evidence regarding the relationship between exposure and injury
What is the threshold for causation in psychiatric injury claims?
Employment must be the predominant cause of the injury
Which of the following could be a compensable consequence of a physical injury?
A psychiatric injury deriving from an underlying physical injury
Which of the following is true about workers’ compensation for employees who travel on behalf of their employer?
They are covered for the entire travel period unless there is a substantial deviation from the agreed route
Who must an employee notify within 30 days if they sustain a work-related injury or illness?
Employer,
What form must an employer provide to an employee within one working day of learning about an injury?
Employee’s Claim for Workers’ Compensation Benefits (DWC 1)
Which of the following workers is NOT covered under the California workers’ compensation system?
Longshore workers
What must an employer do immediately after being notified of a serious injury or death at the workplace?
Report to the Division of Occupational Safety and Health (DOSH)
Which party in the workers’ compensation system typically manages the claims and makes key decisions about benefits?
Claims Administrator
Who is responsible for ensuring that an employee’s work environment is safe and healthful?
Employer
What is the maximum number of chiropractic visits an injured employee can have after January 1, 2004, unless authorized for more?
24 visits
Which of the following tasks is typically NOT the responsibility of a claims administrator?
Filing legal claims against the employer
What is required for an employee to change their treating physician to a personal chiropractor after a work-related injury?
They must provide the employer with the name and address of the chiropractor before the injury occurs
Which document must an employer complete within five days of being notified of an employee’s occupational injury?
Employer’s Report of Occupational Injury or Illness (Form 5020)
What happens if an employee does not predesignate a personal physician before sustaining a work-related injury?
The claims administrator has the right to select the treating physician within the first 30 days
What is a serious injury as defined by the California workers’ compensation system?
An injury resulting in more than 24 hours of hospitalization for something other than observation
Who must provide the employer with written notice before canceling a workers’ compensation policy?
Insurance Carrier
Under what circumstances can an injured worker’s attorney receive fees directly from the worker’s compensation award?
When the workers’ compensation judge or WCAB authorizes it
What is the primary role of medical case managers employed by insurers in the workers’ compensation system?
To assist in medical and other aspects of the case, including attending physician appointments
What must an employer provide to an employee within one working day of learning about an injury?
Employee’s Claim for Workers’ Compensation Benefits (DWC 1)
What are Temporary Disability (TD) payments based on?
The employee’s average weekly earnings at the time of the injury
How many weeks of Temporary Disability (TD) payments can an injured worker receive if their injury occurred between January 1, 2008, and the present?
104 weeks within five years from the date of injury
What type of disability payments are provided to an employee who does not completely recover from an injury?
Permanent Disability (P payments
For injuries occurring on or after January 1, 2013, what is the maximum amount of the Supplemental Job Displacement Benefit (SJDB) voucher?
$6,000
What happens if an employee with a permanent partial disability does not return to work within 60 days of the termination of Temporary Disability payments?
The employee may qualify for a Supplemental Job Displacement Benefit (SJD voucher
Which of the following is covered under Death Benefits in the workers’ compensation system?
Burial expenses up to $10,000 for injuries on or after January 1, 2013
What is the purpose of the Return-to-Work Fund?
To make supplemental payments to workers whose permanent disability benefits are disproportionately low in comparison to their earnings loss
What is the penalty if an employer discriminates against an employee for filing a workers’ compensation claim?
The employer may face legal action and be required to compensate the employee
Who is responsible for ensuring that an injured worker receives appropriate benefits in a timely fashion?
The treating physician
What is the maximum amount of burial expenses covered under Death Benefits for injuries occurring before January 1, 2013?
$5,000
Which benefit compensates employees who are permanently unable to return to their pre-injury job due to a work-related injury?
Permanent Disability (P, Temporary Partial Disability (TP
What must an employer do if they fail to provide the necessary medical treatment within one working day after a claim is filed?
Allow the worker to self-procure treatment, with the WCAB retaining jurisdiction over reimbursement
How is the amount of Permanent Disability (PD) payments determined?
According to the percentage of disability
What type of disability payments can continue for life after the permanent disability amount is exhausted?
A small pension for workers with permanent partial disabilities of 70% or more
What percentage of an employee’s estimated wage loss is covered by Temporary Partial Disability (TPD) payments?
66%
What is included in Medical Treatment benefits under workers’ compensation?
Interpreter services related to the treatment
Which of the following is NOT covered under workers’ compensation benefits?
Income from work outside the regular job
What happens if an employer offers regular, modified, or alternative work to an injured employee within 60 days of the injury becoming permanent and stationary?
The employee’s disability payments are decreased by 15%
What is the penalty for an employer that terminates an injured worker during the period of temporary disability without proving a business necessity?
Legal action and potential compensation to the employee
Who is primarily responsible for managing the care of an injured worker in California’s workers’ compensation system?
Primary Treating Physician (PTP)
Which of the following is a requirement for an MPN in the California workers’ compensation system?
Must include a mix of doctors specializing in work-related injuries and general medicine
A secondary treating physician is responsible for:
Reporting findings to the Primary Treating Physician (PTP)
What is a Medical Provider Network (MPN)?
A network of providers established by the employer or insurer to treat work-related injuries
Which of the following is NOT a duty of a Primary Treating Physician (PTP)?
Managing the entire care process independently without reporting to any other entity
What is the significance of predesignating a physician in the workers’ compensation system?
The employee’s predesignated physician can treat the worker even if they are not part of the employer’s MPN or HCO
What is a Health Care Organization (HCO)?
A managed care organization certified by the DWC to provide health care to employees injured at work
In the context of the workers’ compensation system, which of the following is a violation of Labor Code § 139.3?
Referring a patient to a facility where the physician has a financial interest without disclosing it
What is required for a physician to use a Physician Assistant (PA) in treating an injured worker?
The physician must evaluate the PA’s ability and provide supervision, with a limit of supervising two PAs at a time
An employee who fails to predesignate a physician will be treated by:
The HCO or MPN selected by the employer
Which of the following statements is TRUE about Medical Provider Networks (MPNs)?
Employees in an MPN must follow the rules and guidelines set by the network
Which of the following best describes the role of a secondary treating physician?
They provide additional opinions or treatment but do not manage the case
What is the purpose of a Health Care Organization (HCO) in the workers’ compensation system?
To manage and deliver medical treatment to employees injured at work
Which of the following is a requirement for an injured worker to receive treatment from a predesignated physician?
The physician must have treated the employee in the past and have the employee’s medical records
Which of the following must be disclosed if a physician has a financial interest in a facility to which they are referring a patient?
The financial interest the physician has in the facility
What role does a Primary Treating Physician (PTP) play in determining an injured worker’s eligibility for vocational rehabilitation?
They determine medical eligibility for vocational rehabilitation services for injuries before January 1, 2004
In which of the following situations is a cross-referral considered legal?
When two doctors, without any financial interest, refer patients to each other based solely on patient care needs
Which statement is TRUE regarding the supervision of Physician Assistants (PAs) under California workers’ compensation law?
PAs must have all care they provide supervised and approved by a licensed physician
What must an employer provide when contracting with a Health Care Organization (HCO)?
A choice of at least one HCO and an open enrollment period for employees
If an employee is dissatisfied with the medical treatment provided by the MPN, what is their next step?
The employee must request a second opinion from another doctor within the MPN
What is the deadline for submitting the Doctor’s First Report of Occupational Injury or Illness (DFR) after the injured worker’s first visit?
5 working days
Which report is required to document the ongoing treatment and condition of an injured worker during active treatment?
Primary Treating Physician’s Progress Report (PR-2)
What must a treating physician include when requesting treatment through a Request for Authorization (RFA) form?
Documentation substantiating the need for the requested treatment
When should a Primary Treating Physician (PTP) submit a Permanent and Stationary Report (PR-3 or PR-4)?
When the employee’s condition becomes stable and unlikely to improve
If a physician fails to submit a Doctor’s First Report of Occupational Injury or Illness (DFR), what consequences might arise?
The injured worker’s benefits may be delayed, and the physician may face civil penalties
What information is NOT required in the Doctor’s First Report of Occupational Injury or Illness (DFR)?
The estimated cost of treatment
What triggers the need for a Primary Treating Physician’s Progress Report (PR-2)?
All of the above
Which form must be completed by a treating physician to request diagnostic tests or other medical services for an injured worker?
Request for Authorization (RFA)
Under what circumstances is a specialist required to complete a Doctor’s First Report of Occupational Injury or Illness (DFR)?
Only if the treating physician has not already submitted a DFR
What is the purpose of the Permanent and Stationary Report (PR-3 or PR-4)?
To document the injured worker’s condition once it becomes stable and unlikely to improve
How often must a Primary Treating Physician (PTP) submit progress reports during periods of active treatment?
At least every 45 days
Which of the following is required in the Permanent and Stationary Report (PR-3 or PR-4)?
A history of the injury and the patient’s complaints
If a treating physician makes a verbal request for treatment, what must they do next?
Confirm the request in writing using the Request for Authorization (RFA) form
Which form is used to assess the existence and extent of permanent impairment after an employee’s condition becomes permanent and stationary?
Permanent and Stationary Report (PR-3 or PR-4)
What should a PTP do if the injured worker’s condition requires new durable medical equipment or orthotic devices?
Report the need in a Primary Treating Physician’s Progress Report (PR-2)
What is the primary purpose of Evidence-Based Medicine (EBM)?
To integrate the best available research evidence with clinical expertise and patient values
Which schedule must be followed when evaluating and treating ill and injured workers in California?
Medical Treatment Utilization Schedule (MTUS)
Which concept is central to the treatment of work-related injuries according to the MTUS?
Functional improvement
The MTUS is presumed correct on the issue of medical treatment. How can this presumption be successfully challenged?
By providing high-quality scientific medical evidence
What is the role of the Medical Evidence Evaluation Advisory Committee (MEEAC)?
To provide recommendations on updates to the MTUS
Which of the following is NOT a clinical topic covered by the MTUS?
Cardiac conditions
What does the MTUS provide for medical providers?
Treatment frequency, intensity, and duration recommendations
What is the most recent role clarified in the MTUS revisions?
The role of the MTUS as the standard of medical care for work-related illness or injury
Which model is highlighted in the MTUS for understanding chronic pain?
Biopsychosocial
What is functional improvement as defined by the MTUS?
Clinically significant improvement in activities of daily living or reduction in work restrictions
The MTUS is periodically updated to include new evidence. Which guideline chapters are specifically mentioned as being incorporated?
ACOEM and ODG
According to the MTUS, which factor is a better predictor of chronic pain than clinical findings?
Psychosocial factors
What is the primary goal of Utilization Review (UR) in workers’ compensation?
To avoid unnecessary testing and treatments that may be harmful and costly
Who is required by law to have a Utilization Review (UR) program in place?
All employers or their workers’ compensation claims administrators
What must be filed with the DWC Administrative Director as part of the UR program?
UR plans
Who can approve a treatment request in the Utilization Review (UR) process?
Any member of a UR organization
In what situation must a treatment request be reviewed by a physician during the UR process?
When the request is not approved at the adjuster or claims representative level
What can a chiropractic physician reviewer evaluate during the UR process?
Tests or treatments within the scope of chiropractic practice
How soon must a decision be communicated to the treating doctor after a concurrent or prospective request?
Within 5 working days
What happens if additional information needed for a UR decision is not received within 14 days?
The request is denied
Which of the following describes “Prospective Review” in the UR process?
Review conducted prior to the delivery of medical services
What is the maximum timeframe for making a decision related to an expedited review in the UR process?
72 hours
What is the main purpose of Independent Medical Review (IMR) in California’s workers’ compensation system?
To resolve disputes about the medical treatment of injured employees
Who can request an Independent Medical Review (IMR)?
The injured employee or their designee
What must be submitted with the IMR application within 30 days to request a review?
Signed IMR application and a copy of the UR denial or modification
What could cause an IMR to be terminated?
The treatments in dispute are authorized
Who must make decisions on the medical necessity of treatment requests during IMR?
Licensed physicians knowledgeable in the treatment of the injured worker’s condition
What is the highest-ranking standard to be used when making medical necessity decisions during IMR?
The Medical Treatment Utilization Schedule (MTUS)
Within how many days must the final IMR decision be provided in writing to all parties?
14 days
On what grounds can an IMR decision be appealed?
The final determination was procured by fraud
What must be done if a UR decision also involves a dispute of liability?
The request for IMR is extended to 30 days after the liability dispute is resolved
What is required for an expedited IMR request?
The treating physician’s certification that the employee faces an imminent and serious threat to their health
What role do physicians play in disability evaluations?
Determining the impairment rating and eligibility for disability payments
Which of the following forms might a Primary Treating Physician (PTP) use to report a permanent disability?
DWC PR-3 or PR-4
What is the purpose of the Disability Evaluation Unit (DEU)?
To assign permanent disability ratings based on physicians’ evaluations
Which of the following is NOT a required component of a final disability evaluation report?
Workers’ compensation insurance policy number
What does the term “Permanent and Stationary” (P&S) indicate in a disability evaluation?
The worker’s condition has stabilized and is unlikely to improve further
What is the Almaraz-Guzman Standard used for?
Rebutting a permanent disability rating when the AMA Guides are deemed inadequate
According to the AMA Guides, what is the definition of “impairment”?
A loss, loss of use, or derangement of any body part, organ system, or organ function
How is “disability” defined according to the AMA Guides?
An alteration of an individual’s capacity to meet personal, social, or occupational demands due to impairment
What is the primary goal of the AMA Guides?
) To provide a standardized, objective approach to evaluating medical impairments
Which method is commonly used in the AMA Guides to assess spinal impairment?
Diagnosis-Related Estimate (DRE)
What is the purpose of the Combined Values Chart in the AMA Guides?
To combine multiple impairment ratings into a single whole person impairment (WPI)
In what scenario might a physician use the Range of Motion (ROM) method for assessing spinal impairment?
When the condition cannot be easily categorized, such as multilevel fusions
What is the maximum additional percentage a physician can add to a Whole Person Impairment (WPI) rating for pain, according to the AMA Guides?
3%,
What is a key difference in how the AMA Guides and the previous system in California evaluate permanent disability?
The AMA Guides focus on impairment related to activities of daily living, rather than work capacity
What must a physician provide when using an alternative rating method under the Almaraz-Guzman Standard?
Substantial medical evidence and a clear rationale for the chosen method
What is NOT a purpose of a disability evaluation in the workers’ compensation system?
To decide the worker’s guilt or innocence in causing the injury
What approach should a physician take when evaluating a worker using an assistive device, according to the AMA Guides?
Evaluate with and without the device when possible
What is the primary focus of a physician’s responsibility when conducting a permanent disability evaluation using the AMA Guides?
Providing an impairment rating
In California, what does the AMA Guides’ approach to pain in disability evaluations involve?
A conservative addition of up to 3% to the WPI rating when pain is greater than normally associated with the injury,
What is required of a physician when documenting the process used to derive an AMA Guides impairment rating?
Thorough documentation of the rationale and references to the relevant AMA Guides sections
What is the primary role of a Qualified Medical Evaluator (QME)?
To conduct medical-legal evaluations in workers’ compensation cases
Who appoints Qualified Medical Evaluators (QMEs) in California?
The Division of Workers’ Compensation Medical Unit
What is required for a physician to be eligible to become a QME?
They must devote at least one-third of their practice to providing direct medical treatment
When can an Agreed Medical Evaluator (AME) be used?
Only if both the employee and employer agree on a physician
What happens if the represented parties cannot agree on an AME?
Either party may request a QME panel to resolve the dispute
How long is the appointment term for a Qualified Medical Evaluator (QME)?
) Two years
Who can request a medical-legal evaluation if there is a disagreement with the treating physician’s evaluation?
Either the employer or the employee
What is the purpose of a medical-legal evaluation in a workers’ compensation case?
To determine medical issues relevant to the workers’ compensation claim
What must the QME do if there is no referral letter accompanying the request for an evaluation?
Determine the relevant issues based on available records and discussion with the injured worker
What is required if an unrepresented employee fails to request a QME panel within 10 days after the employer’s request?
the employer may then request a QME panel
How many QMEs are listed in a QME panel generated by the DWC Medical Unit?
Three
What must a QME report include to be considered complete?
The physician’s findings and the reasons for all opinions
How soon must the employer pay reasonable charges for a medical-legal report under the fee schedule?
Within 60 days
When can a Permanent and Stationary (P&S) report be contested in a workers’ compensation case?
When either party objects to the findings
What must be addressed in all medical-legal reports regarding permanent disability?
The issue of apportionment
What is the primary purpose of a medical-legal report in a workers’ compensation case?
To assist nonmedical personnel in making decisions affecting the worker’s life
Which of the following is a required element in a medical-legal report?
History of present injury or illness
Why is it important for a medical-legal report to be clear, concise, and internally consistent?
To enable nonmedical personnel to make informed decisions
What must be included in the “Identifying Information” section of a medical-legal report?
Date of the report, name of the applicant, and date of injury
How much face-to-face time is required for a psychiatric evaluation in a medical-legal report?
60 minutes
In the context of workers’ compensation, what does “apportionment of disability” refer to?
The degree to which permanent disability is due to pre-existing conditions
Which form must be reviewed and possibly commented on by the physician for unrepresented workers in a QME evaluation?
DEU Form 100
What is the significance of using appropriate terminology in a medical-legal report?
To align with the logic and definitions of workers’ compensation law
What should be included in the “Present Complaints” section of a medical-legal report?
Detailed description of the patient’s current complaints and related activities
What should a physician do if there are conflicting accounts of how the injury occurred?
Provide an opinion conditionally based on each possible scenario
Why is it important to summarize important medical events or conditions in the report?
) To provide context for the injury and its impact on the worker’s disability
What is the role of a physician in determining the cause of injury in a medical-legal report?
To explain how the injury is related to the worker’s employment
What is the primary purpose of Labor Code § 4600 in relation to medical treatment for injured workers?
To guarantee treatment that cures or relieves the effects of the injury
Which type of medical treatment dispute must be resolved through Independent Medical Review (IMR)?
Current medical treatment disputes
Which of the following must a medical-legal report NOT include when discussing future medical treatment?
Exact dollar amounts for future treatment
Why is it important for a physician to provide detailed reasoning for each opinion in a medical-legal report?
To prevent the report from being deemed worthless in the workers’ compensation system
What role does the WCAB play in the evaluation of future medical treatment needs?
They assess the reports from the treating physician and possibly a QME at the time care is requested
What must be disclosed in the medical-legal report regarding other individuals involved in the evaluation process?
Their names, qualifications, and roles in the evaluation
When is a physician required to provide future medical treatment in a workers’ compensation case?
When it is needed to relieve or cure the effects of the injury
What happens if a medical-legal report is submitted without adequate reasoning behind the medical opinions?
The report is considered worthless in the workers’ compensation system
In what situation would the WCAB not be bound by a physician’s estimate of future medical needs?
When reviewing a P&S report
Which of the following must be included in every medical-legal report under penalty of perjury?
A mandatory declaration stating that the report is true and correct
Why should a physician avoid providing finite numbers and dollar amounts for future medical treatment in their reports?
Because the future needs cannot be precisely predicted
What must a physician disclose if they have a significant beneficial interest in a facility used in the evaluation?
Their proprietary interest or co-ownership of the facility
What is the purpose of the Official Medical Fee Schedule (OMFS)?
To establish the maximum allowable fee for services
Which fee schedule is the Physician Fee Schedule based on?
Resource-Based Relative Value Scale (RBRVS)
What is a key element of the RBRVS fee schedule?
Relative value units (RVUs)
How often is the Physician Fee Schedule updated?
Annually
What is required for a medical provider to request an Independent Bill Review (IBR)?
Completion of a second bill review
Which billing form is used by health-care providers for paper submissions?
Form CMS-1500
What is the time limit for submitting a Request for Second Bill Review after receiving an Explanation of Review (EOR)?
90 days
What factor is used to adjust payments for geographic differences in costs under the RBRVS system?
Geographic Adjustment Factor (GAF)
What does the Multiple Procedure Payment Reduction (MPPR) apply to?
Physical medicine and surgery
What is the primary benefit of electronic billing over paper billing?
Faster payment processing
Which entity currently serves as the Independent Bill Review Organization (IBRO) for California workers’ compensation?
Maximus Federal Services
What is the basis for calculating maximum fees for anesthesia services under the Physician Fee Schedule?
A separate conversion factor for anesthesia, A single national conversion factor
What must be included with a Request for Second Bill Review?
Additional documentation supporting the billing
How are missed appointments communicated under California Specific Codes?
WC012
What is required for a provider to appeal an IBR determination?
Filing with the Workers’ Compensation Appeals Board (WCA
Which regulation outlines the formulas for calculating fees for services other than anesthesia?
8 CCR §9789.12.2
What is the deadline for claims administrators to pay an electronic bill after receiving it?
15 days
Which billing format is consistent with HIPAA standards in California workers’ compensation?
Electronic Billing
What happens if an IBR application is withdrawn after assignment to an IBRO?
The fee will not be reimbursed
What is one of the ground rules that differ from Medicare under the Physician Fee Schedule?
Multiple Procedure Payment Reduction (MPPR) for Radiology Diagnostic Imaging
What is the main responsibility of the DWC Audit and Enforcement Unit?
To conduct audits of claims administrators to ensure compliance with workers’ compensation laws
How often are claims administrators normally subject to routine investigations?
Once every five years
What triggers a targeted investigation of a claims administrator by the DWC?
A credible complaint or failure of a routine investigation
What happens if a URO fails a routine investigation?
The DWC may return for a targeted investigation
What must MPNs and HCOs demonstrate to maintain approval or certification?
Compliance with regulations regarding employee notifications and provider lists
Who can file complaints about the behavior of Qualified Medical Evaluators?
Injured workers, attorneys, and claims administrators
What disciplinary actions can the DWC take against a QME for violations?
Formal reprimand, suspension, or revocation of QME status
Under what circumstances can a QME be suspended without a hearing?
If their medical license has been revoked
What is the role of the DWC Medical Unit in overseeing UROs?
Investigating compliance with UR regulations and assessing penalties
Which of the following is NOT a potential ground for QME disciplinary action?
Failure to pay administrative fees on time
What is the main purpose of the DWC’s investigation of UROs?
To ensure that responses to physicians’ requests for treatment are timely and comply with regulations
Who is responsible for overseeing employers’ compliance with regulations related to workers’ compensation insurance?
The Division of Labor Standards and Enforcement and the Department of Insurance
What is the primary responsibility of a treating physician in the workers’ compensation system?
To treat the patient fairly and ethically
What role does the Labor Code play in regulating medical-legal evaluations?
It clarifies and codifies the role of evaluating physicians
Why might the appearance of impropriety develop in workers’ compensation cases?
Physicians may have business relationships with parties involved
What is a QME required to do when conducting a medical-legal evaluation?
Personally examine the applicant and take a thorough history
According to the chapter, what should a physician do if a worker refuses to provide information or sign a release?
Litigate the issue before the WCAB
Which of the following is true about the use of interpreters during medical-legal evaluations?
The employer or insurance company must provide a certified interpreter
What is one key difference between a treating physician’s report and a QME’s report?
A treating physician’s report is not generated from a disputed issue
What is a physician advised to do if an injured worker appears nervous or evasive during an exam?
Understand the worker’s possible apprehension and try to be objective
What should a QME mention in their report if a certified interpreter was used?
The interpreter’s name
In what scenario might a QME exam be recorded?
If both parties agree and the QME consents to the recording
What is the maximum time an injured worker can be kept waiting before they can terminate the QME exam?
1 hour
Under which condition can a QME terminate an exam?
If the injured worker is intoxicated
If an injured worker terminates an exam due to discriminatory conduct, what is the next step?
The worker may request a new QME
What happens if a judge determines there was no good cause for terminating the QME exam?
The cost of the evaluation is deducted from the worker’s award
Can a QME become a treating physician after conducting an evaluation?
Yes, but only if the injured worker requests it
Under what condition may a QME provide treatment to an injured worker after the evaluation?
If the injured worker formally requests the QME as their treating physician
What must a QME do if they disagree with the treating physician’s assessment that the worker’s condition is permanent and stationary?
Discuss the basis for their disagreement in the report
In what scenario is ex parte communication allowed for a QME?
When requesting medical records in writing with a copy served on the injured worker
What is considered ex parte communication by a QME?
Contacting the defense attorney for additional records without informing the injured worker
How should a QME handle receiving nonmedical records or films?
They should only view them if neither party objects
Who has the initial discretion to terminate a QME exam due to violations of ethical guidelines?
The injured worker
What must a QME do after rescheduling an appointment due to a delay?
Inform the claims administrator of the new appointment time within five days
When can an injured worker terminate a QME exam due to improper conduct?
If the evaluator makes improper sexual advances
What must happen if a new QME examination is necessary after a QME becomes the treating physician?
A new QME panel must be requested
What is a QME prohibited from doing regarding nonmedical records if a party objects?
Viewing the nonmedical records or films
What is required on bills submitted by treating physicians for injured workers?
A declaration that they were not in violation of Labor Code § 139.3 (self-referral)
Which types of self-referrals are specifically prohibited?
Referrals to facilities where the physician or their family has a financial interest
What must a physician do if they refer a patient to a facility in which they have a financial interest?
Disclose their financial interest to the patient
In what case is a physician not required to obtain preauthorization for physical therapy referrals?
When the physician’s regular practice is outside a metropolitan area with no alternatives available within 25 miles
What is the consequence of violating referral prohibitions under Labor Code § 139.31(e)?
A misdemeanor charge
Under what circumstances may medical records related to HIV status be disclosed without patient authorization?
When the patient claims HIV infection through an employment-related exposure
What should a physician do if they receive a subpoena for medical records related to a work injury?
Respond to the subpoena, but consult with the patient or their attorney first
Which of the following actions is considered a felony under Labor Code § 3219?
Offering compensation to a claims adjuster for referrals
What is required for a valid subpoena related to a workers’ compensation claim?
The injured worker must receive a copy of the subpoena
What should treating physicians explain to patients about confidentiality in workers’ compensation cases?
How their medical information will be shared with employers and insurers
What are QMEs and AMEs required to ensure in their evaluations?
Maximum compensation for the injured worker
Which of the following is considered appropriate advertising for QMEs?
Listing the physician’s area of practice and languages spoken
What is the penalty for making false or fraudulent workers’ compensation claims?
Up to five years in prison or a fine of up to $50,000
What must evaluators avoid when providing medical opinions?
Accepting compensation contingent on writing a biased report
Which of the following actions is NOT a violation of the self-referral laws?
Referring a patient for a nonprohibited service with proper disclosure
What should be used to bill for treatment and most reports under California workers’ compensation laws?
Official Medical Fee Schedule
When should the QME Appointment Notification Form be completed and sent to the involved parties?
Within 10 working days of scheduling
If an injured worker makes a QME appointment, what is the maximum number of days allowed before the appointment to avoid difficulties in obtaining records?
25 days
What form must be submitted with the QME evaluation for disability rating by the DEU?
DEU Forms 100 and 101
What must be included in the total package sent to the DEU office for rating a QME evaluation?
QME evaluation, Findings Summary Form, DEU Forms 100 and 101, and Proof of Service
What is the time frame for serving a QME report for injuries occurring after January 1, 1994?
30 days
How long does a QME have to request an extension for a report if test results are delayed?
25 days
Which form must be used to request a time extension for submitting a QME report?
QME Form 112
What should be done if the medical records are not received by the QME appointment date?
Contact the employer/insurer to request records
Who is responsible for serving the QME report to the DWC or WCAB?
The parties involved
What is the fee for requesting Independent Bill Review (IBR)?
$250.00
What happens if a QME report is not completed within the extended time frame?
The original evaluation may be deemed inadmissible
Which form is used to notify the parties about the QME appointment?
QME Form 110
Who must receive a copy of the QME report in a panel QME case for an unrepresented injured worker?
The injured worker, claims administrator, and local DEU office
What is required to consolidate separate IBR requests?
Common issues of law and fact or similar services
What form should be used if an Independent Bill Review request is withdrawn?
No specific form required
What is the maximum amount of a dispute that can be consolidated in IBR?
$4,000,
How should the QME report be served to all parties?
With proof of service attached
If a provider wishes to appeal an IBR determination, how long do they have to file a petition with the WCAB?
20 days
What should be done if the injured worker does not have the required DEU Forms 100 and 101?
Have the worker complete Form 100 at the appointment and ensure Form 101 is received
What does “AA or A/A” stand for in workers’ compensation terminology?
Applicant’s attorney
What is an “Accepted claim” in workers’ compensation?
A claim in which the insurance company agrees that an employee’s injury or illness is covered by workers’ compensation
What does “ACOEM” stand for?
American College of Occupational and Environmental Medicine
Who is the “AD” in the context of workers’ compensation?
Administrative Director of the Division of Workers’ Compensation
Which of the following best defines “ADA”?
Americans with Disabilities
What does “ADL” stand for in the workers’ compensation field?
Activities of Daily Living
Which of the following is the role of an “Administrative Law Judge (WCALJ, ALJ, Judge)”?
To preside over disputes in workers’ compensation cases
What is an “Aggravation” in the context of workers’ compensation?
A worsening of a non-industrial pre-existing condition due to work exposure
Who is an “Agreed medical evaluator (AME)”?
The doctor agreed upon by the worker’s attorney and the insurance company
What is an “Agreed QME”?
An evaluator chosen when an objection is made to an issued panel and both parties agree on the QME
What is meant by “Alternative work” in the workers’ compensation system?
A new job offered by the former employer that meets the employee’s work restrictions
What is the “American Medical Association (AMA)” known for in workers’ compensation?
Publishing the “Guides to the Evaluation of Permanent Impairment”
What does “AOE” stand for in the context of a workers’ compensation claim?
Arising Out of Employment
What is the role of the “Appeals board” in workers’ compensation?
To review and reconsider decisions of workers’ compensation administrative law judges
Who is typically the “Applicant” in a workers’ compensation case?
The injured employee who files a claim
Who does an “Applicants’ attorney” represent in a workers’ compensation case?
The injured employee
What is an “Application for adjudication of claim”?
A form filed to open a case at the Workers’ Compensation Appeals Board office
What does “Apportionment” determine in a workers’ compensation case?
How much of an employee’s permanent disability is due to the work injury versus other causes
What does “AOE/COE” mean in workers’ compensation?
Arising Out of and Occurring in the Course of Employment
What is the role of the “Audit Unit” in the Division of Workers’ Compensation?
Ensuring that insurance companies, self-insured employers, and third-party administrators adhere to the regulations and laws governing workers’ compensation claims.
What does an “Award” refer to in the workers’ compensation system?
A decision by the Workers’ Compensation Appeals Board regarding benefits
What does “AWW or AWE” stand for in workers’ compensation?
Average Weekly Wage or Earnings
Fair Employment and Housing Act (FEHA) prohibits discrimination against:
People with disabilities
The Family and Medical Leave Act (FMLA) provides up to how many weeks of unpaid, job-protected leave per year?
12 weeks
Filing refers to:
Sending or delivering a document to an employer or a government agency
A Final Order is:
An order, decision, or award made by a workers’ compensation judge that has not been appealed
Findings & Award (F&A) is:
A written decision by a workers’ compensation administrative law judge about an employee’s case
First Aid in the workers’ compensation system refers to:
Treatment provided by a physician or licensed medical provider on a one-time basis for a minor condition
A Flare-up of a Pre-Existing Condition is also known as:
Recurrence of a Pre-Existing Condition
Fraud in the workers’ compensation system involves:
Knowingly making a false statement to obtain or deny workers’ compensation benefits
Functional Capacity Evaluation (FCE) is:
A formal assessment of an individual’s physical capabilities
Future Earning Capacity (FEC) refers to:
A multiplier that increases the disability rating based on wage loss caused by an injury
Future Medical Treatment is:
Treatment anticipated at some time in the future to cure or relieve the effects of an injury
Ghostwriting in medical-legal reports is:
When a medical report is prepared by someone other than the physician who performed the evaluation
A Health Care Organization (HCO) is:
An organization certified by the DIR to provide managed medical care within the workers’ compensation system
Hearings in the workers’ compensation system are:
Legal proceedings where a judge discusses issues in a case or receives information
Impairment is defined as:
The reduction or loss of function of an organ or body part
An Impairment Rating is:
A percentage estimate of how much normal use of the worker’s injured body parts has been lost
In Pro Per refers to:
An injured worker not represented by an attorney and acting as their own attorney
An Independent Contractor is someone who:
Has control over how their work is done and is not considered an employee
An Independent Medical Examiner (IME) is:
The same as a Qualified Medical Examiner (QME)
The Industrial Medical Council (IMC):
No longer exists and is now called the Medical Unit
Independent Medical Review (IMR) allows an employee to:
Seek a second and third opinion if they dispute their physician’s recommended tests or treatments
An Information & Assistance (I&A) Officer:
Answers questions and assists injured workers within the DWC
The Information & Assistance Unit (I&A):
Provides information and informally resolves disputes in workers’ compensation claims
An Injured Worker is:
Another term for an injured employee or applicant
Injury in the workers’ compensation system refers to:
A new injury, illness, or a pre-existing condition made worse by work-related exposure
