5. QME Availability and Reports 2

Question 1

What is the importance of declaring the information under penalty of perjury?

Answer 1

Declaring the information under penalty of perjury emphasizes the legal consequences of providing false information thus ensuring the integrity of the information submitted.

Question 2

Why is it important for the physician’s CV to include practice time devoted to medical treatment?

Answer 2

Including the percentage of practice time devoted to medical treatment helps to provide context regarding the physician’s experience and expertise in the relevant medical field which can affect their credibility as a QME.

Question 3

What should any QME inform the Medical Director of if they are unavailable?

Answer 3

Any QME who is unavailable must inform the Medical Director pursuant to section 33 of Title 8 of the California Code of Regulations.

Question 4

Can a physician who has treated an employee as a primary or secondary physician perform a QME evaluation on that employee?

Answer 4

No a physician who has served as a primary treating physician or secondary physician and has provided treatment to the employee for the disputed injury in accordance with section 9785 of Title 8 of the California Code of Regulations shall not perform a QME evaluation on that employee.

Question 5

What should a physician do if contacted to perform a QME evaluation but their name is on the QME panel?

Answer 5

If a physician’s name appears on a QME panel and they are contacted by a party to perform the evaluation they shall disqualify themselves.

Question 6

What can either party do if they want a replacement QME due to disqualification?

Answer 6

Either party may request a replacement QME pursuant to section 31.5 of Title 8 of the California Code of Regulations.

Question 7

What is required to issue a QME panel in a selected specialty?

Answer 7

To issue a panel in a selected specialty there must be at least five active QMEs in that specialty at the time the panel selection is requested.

Question 8

What happens if there are fewer than five active QMEs in a requested specialty when a panel selection is requested?

Answer 8

If there are less than five active QMEs in the requested specialty the Medical Director shall contact the appropriate parties (not specified in the available text but typically relevant regulatory offices or organizations) for further action.

Question 9

What party holds the legal right to designate the specialty for an alternate specialty selection?

Answer 9

The party who holds the legal right to designate the specialty for an alternate specialty selection is specified in the relevant section but is not explicitly mentioned in the provided text.

Question 10

How are disputes regarding the validity of panel requests resolved in represented cases?

Answer 10

Disputes regarding the validity of panel requests shall be resolved by a Workers’ Compensation Administrative Law Judge.

Question 11

What is the process for resolving disputes regarding the appropriateness of the specialty designated?

Answer 11

Disputes regarding the appropriateness of the specialty designated shall be resolved pursuant to section 31.5a10 of Title 8 of the California Code of Regulations.

Question 12

Can either party appeal the Medical Director’s decision about the appropriateness of the specialty?

Answer 12

Yes either party may appeal the Medical Director’s decision as to the appropriateness of the specialty to a Workers’ Compensation Administrative Law Judge.

Question 13

What happens if the Medical Director is unable to issue a QME panel within thirty (30) calendar days in a represented case?

Answer 13

If the Medical Director is unable to issue a QME panel in a represented case within thirty (30) calendar days of receiving the request either party may seek an order from a Workers’ Compensation Administrative Law Judge that a QME panel be issued.

Question 14

What must every order from a Workers’ Compensation Administrative Law Judge specify regarding the QME panel?

Answer 14

Any such order shall specify the specialty of the QME panel or the party to be designated to select the specialty.

Question 15

What is the timeframe for an unrepresented employee to select a QME after receiving the panel form?

Answer 15

The unrepresented employee has ten (10) days to select a QME from the panel list after being furnished with the form.

Question 16

What must the unrepresented employee do after selecting a QME?

Answer 16

The unrepresented employee must contact the selected QME to schedule an appointment and inform the claims administrator of the QME selection and the appointment.

Question 17

Are employers or their representatives allowed to discuss the selection of the QME with an unrepresented worker?

Answer 17

No neither the employer nor the claims administrator nor any other representative of the employer shall discuss the selection of the QME with an unrepresented worker who has the legal right to select the QME.

Question 18

What happens if an unrepresented employee does not select a QME within ten days of the issuance of the QME panel?

Answer 18

If the unrepresented employee fails to select a QME or fails to schedule an appointment within ten (10) days the claims administrator may schedule an appointment with a panel QME as provided in Labor Code section 4062.1c and must notify the employee of the appointment.

Question 19

What section of the Labor Code provides guidelines for the claims administrator’s actions if an unrepresented employee fails to select a QME?

Answer 19

Labor Code section 4062.1c.

Question 20

When the employee is represented by an attorney what procedural changes apply regarding the selection of a QME?

Answer 20

The text does not provide information on the specific procedural changes when the employee is represented by an attorney but it implies that different protocols must be followed when an attorney is involved.

Question 21

What happens after parties have completed the striking processes in Labor Code section 4062.2c?

Answer 21

After completing the striking processes described in Labor Code section 4062.2c the represented employee must schedule an appointment with the physician selected from the Qualified Medical Evaluator (QME) panel.

Question 22

What is the timeframe for a represented employee to schedule an appointment with the selected QME?

Answer 22

The represented employee must schedule the appointment within ten (10) business days of the date a QME is selected from the panel.

Question 23

What occurs if the represented employee does not schedule the appointment within the allocated timeframe?

Answer 23

If the represented employee fails to schedule the appointment within ten (10) business days the claims administrator or the administrator’s attorney may arrange the appointment and notify the employee and the employee’s attorney.

Question 24

What can a party do if they cannot obtain an appointment with a selected QME within ninety days?

Answer 24

If a party with the legal right to schedule an appointment with a QME is unable to obtain an appointment within ninety (90) days of the request that party may waive the right to a replacement QME in order to accept an appointment no more than one-hundred twenty (120) days after the initial request.

Question 25

What happens if the selected QME cannot schedule an evaluation within the one-hundred-twenty-day timeframe?

Answer 25

If the selected QME is unable to schedule the evaluation within one-hundred twenty (120) days of the initial appointment request either party may report the issue.

Question 26

What is a QME in the context of Labor Code section 4062.2c?

Answer 26

A Qualified Medical Evaluator (QME) is a physician selected from a panel to evaluate an employee's medical condition typically in the context of workers' compensation claims.

Question 27

What is the purpose of the striking process described in Labor Code section 4062.2c?

Answer 27

The striking process allows parties to remove certain evaluators from a list of QMEs to ensure an impartial and fair selection for a medical evaluation.

Question 28

How long does a party have to wait after their initial request for an appointment before they can accept a scheduled appointment beyond the initial selection?

Answer 28

A party may accept a scheduled appointment no later than one-hundred twenty (120) days after the date of the party's initial request for an appointment.

Question 29

In what situation can a claims administrator arrange the appointment with a QME?

Answer 29

The claims administrator can arrange the appointment with a QME if the represented employee fails to schedule it within ten (10) business days post-selection.

Question 30

What notification is required when a claims administrator arranges the QME appointment?

Answer 30

The claims administrator must notify both the employee and the employee's attorney when arranging the appointment.

Question 31

What happens if the initially selected Qualified Medical Evaluator (QME) is unavailable?

Answer 31

If the initially selected QME is unavailable the Medical Director shall issue a replacement pursuant to section 31.5 of Title 8 of the California Code of Regulations upon request. This is unless both parties agree in writing to waive the 120-day time limit for scheduling the initial or any subsequent evaluation.

Question 32

What is the 120-day time limit related to in the context of a QME evaluation?

Answer 32

The 120-day time limit refers to the maximum time allowed for scheduling the initial QME evaluation or any subsequent evaluation which can be waived if both parties agree in writing.

Question 33

To what evaluations does subdivision e of the regulations apply?

Answer 33

Subdivision e of the regulations applies to both requests for any Comprehensive Medical-Legal Evaluation by a QME and requests for Follow-Up Comprehensive Medical-Legal Evaluations by a QME.

Question 34

What are the conditions under which a replacement QME might be requested?

Answer 34

A replacement QME may be requested under the following conditions: 1. A QME on the panel issued does not practice in the specialty requested by the party holding the legal right to request the panel. 2. A QME on the panel issued cannot schedule an examination.

Question 35

What authority does the Medical Director have regarding QME selection?

Answer 35

The Medical Director has the authority to select a replacement QME or at their discretion replace the entire panel of QMEs. This selection is done at random upon request.

Question 36

What is the procedure for requesting a replacement QME?

Answer 36

A replacement QME can be requested when any of the specified conditions occur and the Medical Director will select a new QME at random and provide it upon request.

Question 37

What section of the California Code of Regulations addresses QME replacements?

Answer 37

Section 31.5 of Title 8 of the California Code of Regulations addresses QME replacements.

Question 38

What types of evaluations are included in the terms of 'Comprehensive Medical-Legal Evaluation' and 'Follow Up Comprehensive Medical-Legal Evaluations'?

Answer 38

Both 'Comprehensive Medical-Legal Evaluation' and 'Follow Up Comprehensive Medical-Legal Evaluations' refer to evaluations conducted by a Qualified Medical Evaluator for purposes related to legal claims including but not limited to workers' compensation cases.

Question 39

Can parties agree to extend the time for scheduling evaluations?

Answer 39

Yes both parties can agree in writing to waive the 120-day time limit for scheduling the initial or any subsequent evaluation.

Question 40

What is the significance of having a QME with the appropriate specialty?

Answer 40

Having a QME with the appropriate specialty is crucial because it ensures that the evaluator has the relevant expertise and qualifications needed to provide an accurate assessment related to the specific medical issues at hand.

Question 41

What is the time limit for a QME to schedule an examination after the initial request for an appointment?

Answer 41

The QME must schedule the examination within ninety (90) days of the initial request. If the 90-day scheduling limit has been waived pursuant to section 31.3e of Title 8 of the California Code of Regulations then the exam cannot be scheduled within one hundred twenty (120) days of the initial request.

Question 42

What must happen if the injured worker changes their residence address after the QME panel has been issued?

Answer 42

If the injured worker has changed their residence address since the QME panel was issued and prior to the date of the initial evaluation this may affect the scheduling of the examination.

Question 43

Define 'group practice' as it relates to the QME panel under Labor Code section 139.3.

Answer 43

A group practice refers to a group of two or more physicians who share the same facility and who provide healthcare services. If a physician on the QME panel is a member of the same group practice as another QME on the panel it could impact the scheduling of the examination.

Question 44

What are the conditions under which a QME may be deemed 'unavailable'?

Answer 44

A QME may be deemed unavailable under section 33 which outlines specific circumstances when they cannot fulfill their duties affecting scheduling.

Question 45

What should be done if the evaluator who previously reported in the case is no longer available?

Answer 45

If the evaluator who previously reported in the case is no longer available this may create a need for rescheduling the examination or finding a substitute evaluator.

Question 46

Under what conditions can a QME named on the panel not serve if they were the employee's primary or secondary treating physician?

Answer 46

If a QME named on the panel is currently or has been the employee's primary treating physician or secondary physician in relation to the injury then they cannot serve in that capacity according to section 9785 of Title 8 of the California Code of Regulations.

Question 47

What is the role of a QME (Qualified Medical Evaluator) in the California workers' compensation system?

Answer 47

The role of a QME is to provide an independent medical evaluation of an injured worker to determine the extent and cause of their injuries medical treatment needs and disability status.

Question 48

Describe the implications of using a doctor related by practice on a QME panel.

Answer 48

The presence of multiple QME panel members related by practice in the same group may lead to biases or conflicts of interest potentially affecting the fairness and objectivity of the evaluation.

Question 49

What is the significance of sections 31.3e and 33 in scheduling QME examinations?

Answer 49

Section 31.3e addresses the conditions under which the 90-day scheduling limit can be waived while section 33 specifies the conditions that define a QME's unavailability both of which are critical for understanding scheduling procedures.

Question 50

What legal text outlines requirements for allowable delays in scheduling QME examinations?

Answer 50

The requirements and allowances for delays are outlined in Title 8 of the California Code of Regulations.

Question 51

What is the role of the claims administrator in relation to the replacement panel for an employee's convenience?

Answer 51

The claims administrator or the employer if there is none may agree in writing with the employee that a new panel can be issued in the Geographic Area of the Employee's Work Place. A copy of the employee's agreement must be submitted with the panel replacement request.

Question 52

What is required for the Medical Director to find 'good cause' for replacing a Qualified Medical Evaluator (QME) or panel?

Answer 52

The Medical Director must receive a written request and find good cause related to the medical nature of the injury. 'Good cause' is defined as a documented medical or psychological impairment.

Question 53

What documentation must accompany the Medical Director's written request when seeking a replacement QME or panel?

Answer 53

The written request must include a copy of the Doctor's First Report of Occupational Injury or Illness (Form DLSR 5021) as per 8 Cal. Code Regs. 14006 and 14007 as well as the most recent DWC Form PR-2 'Primary Treating Physician's Progress Report' as per 8 Cal. Code Regs. 9785.2 or a narrative report filed in lieu of these forms.

Question 54

What does 'good cause' refer to in the context of requesting a replacement QME?

Answer 54

'Good cause' refers to a documented medical or psychological impairment that justifies the need for a replacement Qualified Medical Evaluator (QME) or panel.

Question 55

What forms are referenced in the requirement for the Medical Director's replacement request?

Answer 55

The forms referenced are the Doctor's First Report of Occupational Injury or Illness (Form DLSR 5021) and the DWC Form PR-2 'Primary Treating Physician's Progress Report'.

Question 56

What regulations govern the requirements for forms related to occupational injury reports in California?

Answer 56

The requirements for forms related to occupational injury reports in California are governed by 8 Cal. Code Regs. 14006 14007 and 9785.2.

Question 57

What is the significance of submitting an employee's signed agreement for a new panel?

Answer 57

The submission of the employee's signed agreement is significant as it validates the convenience request for a new panel in the appropriate geographic area and is required to be included with the panel replacement request.

Question 58

Who decides if there is 'good cause' for a replacement QME or panel?

Answer 58

The decision on whether there is 'good cause' for a replacement QME or panel is made by the Medical Director.

Question 59

What does PR-2 determine regarding the specialty chosen by the party holding the legal right?

Answer 59

PR-2 determines that the specialty chosen by the party holding the legal right to designate a specialty is medically or otherwise inappropriate for the disputed medical issues.

Question 60

What can the Medical Director request from either party in PR-2 evaluations?

Answer 60

The Medical Director may request either party to provide additional information or records necessary for the determination.

Question 61

What section does the evaluator violate if they do not comply with Appointment Notification and Cancellation?

Answer 61

The evaluator has violated section 34 Appointment Notification and Cancellation of Title 8 of the California Code of Regulations.

Question 62

Under what condition will the evaluator not be replaced due to the violation of section 34?

Answer 62

The evaluator will not be replaced for this reason whenever the request for a replacement by a party is made more than fifteen (15) calendar days from either the date the party became aware of the violation of section 34 or the date the report was served by the evaluator whichever is earlier.

Question 63

What deadlines are specified that the evaluator failed to meet?

Answer 63

The evaluator failed to meet the deadlines specified in Labor Code section 4062.5 and section 38 Medical Evaluation Time Frames of Title 8.

Question 64

What is the purpose of section 34 of Title 8 of the California Code of Regulations?

Answer 64

Section 34 of Title 8 of the California Code of Regulations pertains to the notification and cancellation of appointments related to medical evaluations.

Question 65

What does Labor Code section 4062.5 pertain to?

Answer 65

Labor Code section 4062.5 pertains to the requirements and timelines for medical evaluations in the workers' compensation sector.

Question 66

What are the implications of not adhering to Medical Evaluation Time Frames in Title 8?

Answer 66

Not adhering to Medical Evaluation Time Frames can lead to delays in the resolution of medical disputes and may affect the legal proceedings regarding workplace injuries.

Question 67

What is the significance of a party becoming aware of a violation?

Answer 67

The significance of a party becoming aware of a violation is critical as it triggers the timeline for requesting a replacement evaluator under section 34 of Title 8.