3. Ethical Standards 2

Question 1

What constitutes ‘good cause’ for an Appeals Board determination when an injured worker terminates the examination?

Answer 1

A violation of section 40 or any part of section 41a or 41.5 by the evaluator shall constitute good cause for purposes of an Appeals Board determination.

Question 2

Are parties liable for the cost of medical reports or medical evaluations?

Answer 2

No party shall be liable for any cost for medical reports or medical evaluations.

Question 3

If an injured worker claims a violation of which sections can the process be terminated?

Answer 3

The injured worker can terminate the examination process based on an alleged violation of section 35k 40 41a or 41.5 of Title 8 of the California Code of Regulations.

Question 4

What role does the Administrative Director have in the process of evaluation and termination of examinations?

Answer 4

The Administrative Director oversees the regulations applicable to the evaluations and the process surrounding them ensuring that parties adhere to the guidelines.

Question 5

What should occur if both parties do not agree on rescheduling an evaluation?

Answer 5

If both parties do not agree the evaluation may not proceed as planned but the decision would depend on further assessment of the situation.

Question 6

What defines ‘good cause’ in the context of evaluation terminations?

Answer 6

‘Good cause’ in evaluation terminations can be defined as violations of specific sections in the regulations by the evaluator.

Question 7

What is the implication for an injured worker’s award if the evaluation cannot be justified due to no good cause?

Answer 7

The cost of the evaluation shall be deducted from the injured worker’s award.

Question 8

What circumstances justify the termination of a medical-legal evaluation for good cause according to the document?

Answer 8

An evaluator can terminate a medical-legal evaluation for good cause if the injured worker or their representative uses abusive language towards the evaluator or staff or attempts to disrupt the evaluator’s office operations.

Question 9

What must the evaluator provide upon terminating the evaluation process?

Answer 9

The evaluator must state under penalty of perjury the facts supporting the termination of the evaluation process.

Question 10

Who has the authority to investigate the termination of a medical-legal evaluation?

Answer 10

Upon request the Medical Director has the authority to investigate the facts and make a final determination regarding the issues related to the evaluation termination.

Question 11

What is the evaluator’s obligation if the injured worker is intoxicated or under the influence of medication?

Answer 11

The evaluator is not required to undertake or continue the evaluation if the injured worker is intoxicated or under the influence of any medication that impairs their ability to participate in the evaluation process.

Question 12

What consequence does an evaluator face for not providing facts supporting the termination of an evaluation process?

Answer 12

The evaluator must provide the supporting facts under penalty of perjury meaning they could face legal consequences for false statements or failure to provide accurate information.

Question 13

Can an evaluator selected from a panel refuse to carry out an evaluation? If so under what conditions?

Answer 13

Yes an evaluator selected from a panel can refuse to carry out an evaluation if the injured worker is intoxicated or under the influence of medication that affects their ability to participate.

Question 14

Define ‘comprehensive medical-legal evaluation’ in the context of the document.

Answer 14

A comprehensive medical-legal evaluation refers to a thorough assessment conducted by an evaluator to determine the medical and legal ramifications of an injured worker’s condition which may involve physical examinations medical history reviews and consideration of legal factors.

Question 15

What role does the Medical Director play according to the section provided?

Answer 15

The Medical Director is responsible for investigating the facts related to any termination of evaluation processes and making a final determination on the related issues.

Question 16

Is there any protection for evaluators against disruptive actions during evaluations?

Answer 16

Yes evaluators are protected from being required to continue evaluations if the injured worker disrupts the process or uses abusive language.

Question 17

What legal implications does the phrase ‘under penalty of perjury’ carry for evaluators?

Answer 17

The phrase ‘under penalty of perjury’ indicates that the evaluator could face charges for perjury—a serious offense—if they knowingly provide false or misleading information concerning the termination of an evaluation.

Question 18

What must the Medical Director do upon request regarding the evaluation process?

Answer 18

The Medical Director shall investigate the facts and make a final determination of the issues.

Question 19

What does Section 41.5 pertain to in the evaluation process?

Answer 19

Section 41.5 pertains to conflicts of interest by medical evaluators.

Question 20

What restrictions are placed on medical evaluators regarding compensation?

Answer 20

Evaluators shall not request or accept any compensation or other thing of value from any source that does or could create a conflict with their duties as evaluators under the Labor Code or the regulations of the Administrative Director.

Question 21

What is the relevance of the California Code of Regulations Title 8 in the context of medical evaluators?

Answer 21

The regulations of the Administrative Director Title 8 of the California Code of Regulations (Chapters 1 through 1.8) and the Workers’ Compensation Appeals Board (Chapters 1.9 sections 10600 through 10727) provide the framework that governs the conduct of medical evaluators.

Question 22

What does a conflict with the duties of an evaluator mean according to Labor Code section 139.20?

Answer 22

It means having a disqualifying conflict of interest with one or more of the persons or entities described in subdivision c and failing to disclose the fact of the conflict.

Question 23

Where can the definitions and guidelines regarding conflicts of interest for medical evaluators be found?

Answer 23

They can be found in Labor Code section 139.20.

Question 24

What are evaluators required to disclose according to the regulations?

Answer 24

Evaluators are required to disclose any disqualifying conflicts of interest.

Question 25

Can you describe the consequences of failing to disclose a conflict of interest as a medical evaluator?

Answer 25

Failing to disclose a conflict of interest can result in disqualification and potential legal repercussions for the evaluator.

Question 26

What is the role of the Workers' Compensation Appeals Board in relation to medical evaluators?

Answer 26

The Workers' Compensation Appeals Board establishes regulations that govern the evaluation process and the conduct of medical evaluators.

Question 27

What are the specific sections of the California Code of Regulations that address conflicts of interest in evaluation?

Answer 27

Specifically Title 8 of the California Code of Regulations Chapters 1 through 1.8 section 1 et seq. and Chapters 1.9 sections 10600 through 10727.

Question 28

What is the significance of Section 139.20 in relation to medical evaluators?

Answer 28

Section 139.20 outlines what constitutes a conflict of interest for medical evaluators and emphasizes the importance of avoiding such conflicts to maintain integrity in evaluations.

Question 29

Who is included as the injured worker or their representative in a workers' compensation case?

Answer 29

1. The injured worker themselves 2. The injured worker's attorney.

Question 30

Who represents the employer in a workers' compensation case?

Answer 30

1. The employer 2. The employer's attorney.

Question 31

Who is involved in the claims process as representatives from the insurance side?

Answer 31

1. The claims adjuster 2. The insurer 3. The third-party administrator or their attorney.

Question 32

When can a primary treating physician or secondary physician be involved in a case?

Answer 32

They can be involved if the treatment provided by that physician is disputed in the case.

Question 33

What role does the utilization review physician have in a workers' compensation case?

Answer 33

The utilization review physician reviewer can be involved if their opinion is disputed in the case along with any utilization review organization.

Question 34

When can a surgical center be a part of the dispute in a case?

Answer 34

The surgical center is involved only if the need for surgery is disputed in the case.

Question 35

Under what condition can other purveyors of medical goods or services be part of a dispute?

Answer 35

They can be involved only if the medical necessity for using such goods or services is in dispute in the case.

Question 36

What is meant by 'Disqualifying Conflict of Interest' in this context?

Answer 36

'Disqualifying Conflict of Interest' refers to a situation where the evaluator has certain relationships or interests with any person or entity listed in subdivision 41.5c.

Question 37

What types of relationships might create a Disqualifying Conflict of Interest for an evaluator?

Answer 37

The specifics are not detailed in the provided information but generally they would include any financial personal or professional ties to the involved parties (e.g. injured worker employer medical providers) that could influence the evaluator's judgment.

Question 38

What are examples of familial relationships outlined in the document?

Answer 38

The familial relationships include parent child grandparent grandchild sibling uncle aunt nephew niece spouse fiancée or cohabitant.

Question 39

What constitutes a significant disqualifying financial interest according to the document?

Answer 39

A significant disqualifying financial interest includes: 1. Employment or a promise of employment. 2. An interest of 5% or more in the fair market value of any form of business entity involved in workers' compensation matters or of private real property or personal property or in a leasehold interest. 3. 5% or more of the evaluator's income is received from direct referrals by or from contracts with specified persons or entities with exceptions for contracts for participation in a Medical Provider Network as defined under Labor Code section 4616 et seq. 4. A financial interest as defined in Labor Code section 139.3 that precludes referral by the evaluator to a listed person or entity. 5. A financial interest defined under the Physician Ownership and Referral Act of 1993 (PORA).

Question 40

What specific interests are excluded from being a disqualifying financial interest when participating in a Medical Provider Network?

Answer 40

Contracts for participation in a Medical Provider Network as defined under Labor Code section 4616 et seq are excluded from being considered a disqualifying financial interest.

Question 41

According to the document what percentage of interest in a business entity qualifies as a significant financial disqualifier?

Answer 41

An interest of 5% or more in the fair market value of any form of business entity involved in workers' compensation matters qualifies as a significant financial disqualifier.

Question 42

Explain what is meant by 'a financial interest as defined in Labor Code section 139.3'?

Answer 42

A financial interest as defined in Labor Code section 139.3 refers to any financial stake or investment that would create a conflict of interest and preclude an evaluator from making certain referrals to a person or entity.

Question 43

What is the Physician Ownership and Referral Act of 1993 (PORA)?

Answer 43

The Physician Ownership and Referral Act of 1993 (PORA) is legislation that prohibits physician referrals to entities in which they have a financial interest aiming to avoid conflicts of interest in medical referrals.

Question 44

What is the significance of a relationship that includes siblings in terms of financial interests?

Answer 44

Relationships that include siblings can affect conflicts of interest potentially qualifying as familial relationships that might lead to disqualifying financial interests if a sibling is involved in a business or financial arrangement with the evaluator.

Question 45

What does the term 'leasehold interest' refer to in the context of disqualifying financial interests?

Answer 45

A leasehold interest refers to an interest in a property that has been leased which can impact a person's financial standing or relationship with business entities involved in workers' compensation matters.

Question 46

How can direct referrals affect an evaluator's income according to the outlined financial interests?

Answer 46

If 5% or more of the evaluator's income is derived from direct referrals related to contracts with specified persons or entities this could be considered a disqualifying financial interest except for certain excluded contracts.

Question 47

What is covered under Business and Professions Code sections 650.01 and 650.02?

Answer 47

Sections 650.01 and 650.02 outline prohibitions for evaluators regarding conflicts of interest and referrals to individuals or entities where such conflicts exist.

Question 48

What does a 'professional affiliation' mean in the context of medical evaluations?

Answer 48

A professional affiliation refers to the evaluator providing services in the same medical group or business structure that consists of medical evaluators focusing on workers' compensation medical-legal evaluations.

Question 49

What should an evaluator consider regarding relationships or interests not specified in subsections d1 to d3?

Answer 49

Evaluators must consider any relationship or interest that could lead a reasonable person to doubt the evaluator's integrity and impartiality when making medical decisions.

Question 50

What types of relationships can lead to disqualification of an Agreed Medical Evaluator or a Qualified Medical Evaluator?

Answer 50

Disqualifying relationships include doctor-patient relationships familial ties financial interests or professional connections that could lead to an unethical situation in a comprehensive medical-legal assessment.

Question 51

When must an AGreed Medical Evaluator or Qualified Medical Evaluator disqualify themselves?

Answer 51

An evaluator must disqualify themselves if they have a relationship that might compromise their ethical duty to perform an impartial and comprehensive medical-legal evaluation.

Question 52

What ethical considerations are evaluators required to uphold in their assessments?

Answer 52

Evaluators must act with integrity and impartiality avoiding any conflicts of interest that could undermine their professional judgment.

Question 53

What does it mean to act with integrity in the context of medical evaluations?

Answer 53

Acting with integrity means the evaluator conducts themselves honestly and adheres to ethical standards ensuring that their evaluations are objective and free from outside influences.

Question 54

What role do potential conflicts of interest play in the evaluation process?

Answer 54

Potential conflicts of interest necessitate careful consideration and may require disqualification of the evaluator to maintain ethical evaluation standards.

Question 55

What might cause an evaluator to feel it is unethical to perform a medical-legal evaluation?

Answer 55

An evaluator may find it unethical to proceed with an evaluation if they have a significant personal financial or professional relationship with any involved parties or entities.

Question 56

What is the significance of maintaining impartiality in medical evaluations?

Answer 56

Impartiality is crucial to ensure fair and accurate evaluations thus contributing to the credibility of the findings and decisions made based on the evaluations.

Question 57

What is the responsibility of an Agreed Medical Evaluator or Qualified Medical Evaluator regarding conflicts of interest?

Answer 57

An Agreed Medical Evaluator or Qualified Medical Evaluator must send written notification to the injured worker claims administrator (or employer) or their respective attorneys within five business days if they become aware of a disqualifying conflict of interest related to a workers' compensation claim.

Question 58

What information must be included in the written notice of a disqualifying conflict of interest?

Answer 58

The written notice must include: 1) a disclosure that a disqualifying conflict of interest exists 2) the person or entity with whom the conflict arises and 3) the category of conflict (e.g. familial significant financial or other ethical conflicts).

Question 59

What are examples of categories of conflict that must be disclosed by the evaluator?

Answer 59

Examples of categories of conflict that must be disclosed include familial conflicts significant financial conflicts and other types of ethical conflicts.

Question 60

What happens if an evaluator declines to perform an evaluation due to a conflict of interest?

Answer 60

If the evaluator declines to perform an evaluation due to disqualifying themselves the parties involved in the workers' compensation claim must be notified.