QME Eligibility Flashcards
(38 cards)
Section 10. Appointment of QMEs
(a) QME Form 100. / AD certifies applicants to sit for QME competency examination
(b) Applicants on med board probation may sit for exam
(c) No convicted felons or misdemeanors related to practice
(d) Physician who withdraws from QME while under investigation, is subject to reactivation of disciplinary process if files for re-appointment
§11. Eligibility Requirements for Initial Appointment as a QME.
Admin Director shall appoint QME’s who meet reqs in LC sec 139.2 AND
(a) submit the required docs (license to practice in Cal; MD/DO = post-graduate diplomas, board certification or declaration; Psychologists = PhD + 5 years experience; Chiro = WC Evaluation Certification w/ minimum 44 hours
(b) 12-hour report writing course (*exceptions for chiro); SFI Form 124 (Financial Interests)
(c) provide supplemental information if AD requests
(d) shall not treat or offer to treat IW’s under evaluation
(e) declare under penalty of perjury: unrestricted license or terms of restriction; at least 1/3 practice is direct treatment; hasn’t performed QME w/o certification; reported SFI Form 124 financial interests
(f) pass QME Competency Evaluation
(g) pay annual fee prior to appointment
Sec. 11.5 Disability Evaluation Report Writing Course
Prior to appointment QME’s must complete a course of at least 16 hours of instruction in disability evaluation report writing. The course curriculum shall be specified by the Administrative Director.
[education provider and course requirements]
Sec. 14 Doctors of Chiropractic: Certification in WC Evaluation
(a) All chiropractors shall be certified in WC evaluation by either a California professional chiropractic association, or an accredited California college recognized by the Administrative Director. The certification program shall include instruction in disability evaluation report writing.
[entire course 25 hour minimum]
§15. Appointment of Retired or Teaching Physicians.
To become a QME, retired or teaching physicians must pass the QME competency exam and submit written documentation to the Administrative Director that he or she meets either (a), (b) or (c) of this section.
(a) be salaried faculty at an accredited university or college, have a current license and be engaged in teaching, lecturing, published writing or medical research at that university or college in the area of his or her specialty for not less than one-third of his or her professional time. [[The physician’s practice in the three consecutive years immediately preceding the time of application shall not have been devoted solely to the forensic evaluation of disability.]]
(b) Be retired from full-time practice; retain a current license in California; and
(1) Have a minimum of 25 years’ experience; and
(2) Have had a minimum of 10 years’ experience in WC; and
(3) Be practicing currently fewer than 10 hours per week on direct medical treatment; and
(4) Not have engaged in a practice devoted solely to the forensic evaluation of disability during the three consecutive years immediately preceding the time of application.
(c) Be retired from active practice due to a documented medical or physical disability and currently practice in his or her specialty fewer than 10 hours per week. The physician shall have 10 years experience in workers’ compensation medical issues as a physician. The physician’s practice in the three consecutive years immediately preceding the time of application shall not have been devoted solely to the forensic evaluation of disability.
(d) A physician appointed under section 11 of Title 8 of the California Code of Regulations or this section shall, notify the Administrative Director of changes in his or her status and shall complete the requirements for continuing education pursuant to section 55 of Title 8 of the California Code of Regulations prior to reappointment.
§16. Determination of Fees for QME Eligibility.
(a) For purposes of establishing the annual fee for any qualified medical evaluator shall be classified into one of three categories:
(1) QMEs who have conducted 0-10 comprehensive medical-legal evaluations in the twelve months prior to the assessment of the fee.
(2) QMEs who have conducted 11-24 comprehensive medical-legal evaluations in the twelve months prior to assessment of the fee.
(3) QMEs who have conducted 25 or more comprehensive medical-legal evaluations in the twelve months prior to assessment of the fee.
(b) The evaluations shall be conducted in compliance with all applicable statutes and regulations.
(c) Verification of the number of examinations shall be made by the Administrative Director using The Qualified or Agreed Medical Evaluator Findings Summary Form in section 111 (See, 8 Cal. Code Regs. § 111), as well as any other relevant records or sources of information. Misrepresentation of the number of evaluations performed for purposes of establishing a physician’s QME fee shall constitute grounds for disciplinary proceedings under section 60 of this chapter.
§17. Fee Schedule for QME.
(a) All physicians seeking QME status shall be required to pay to the Workers’ Compensation Administration Revolving Fund, the following fee:
(1) QMEs performing 0-10 comprehensive medical-legal evaluations, $110 during each of the years or any part of a year the physician retains his or her eligibility on the approved QME list.
(2) QMEs performing 11-24 comprehensive medical-legal evaluations, $125 during each of the years or any part of a year the physician retains his or her eligibility on the approved QME list.
(3) QMEs performing 25 or more comprehensive medical-legal evaluations, $250 during each of the years or any part of a year the physician retains his or her eligibility on the approved QME list.
(b) The Administrative Director may waive or return the statutory fee in the amount of $110 for the completion of a survey of QMEs to validate the QME competency examination.
(c) At the time of paying the appropriate QME annual fee, each QME shall also complete and forward to the Medical Director with the annual fee a completed QME SFI Form 124, providing updated information about the QME’s specified financial interests as defined in section 29 of Title 8 of the California Code of Regulations.
§18. QME Fee Due Dates.
(a) All physicians, regardless of the number of comprehensive medical-legal evaluations performed under section 17 of Title 8 of the California Code of Regulations shall pay the required QME fees at yearly intervals within 30 days of receipt of notice from the Administrative Director that the QME fee for the next 12 months is due and payable. No physician who has passed the competency examination shall be placed on the active QME roster until the appropriate fee under section 17 has been paid.
(b) Any QME who fails to pay the required statutory fee within 30 days of receipt of a final notice that the fee is due shall be notified that he or she shall be terminated from the official QME roster of physicians within 30 days and shall not perform any panel QME or represented QME comprehensive medical-legal evaluation until the fee is paid.
(c) If the QME fee is not paid within two years from the due date in the final fee notice from the Administrative Director to the QME or QME applicant that the fee is due, then the physician shall resubmit a new application pursuant to Sections 10 and 11 of Title 8 of the California Code of Regulations, pass the QME competency examination and pay the appropriate fee prior to regaining or obtaining QME active status.
§19. Certificate of QME Status.
(a) Upon receipt of the QME fees and review by the Administrative Director to ensure current compliance with section 139.2 of Labor Code and any other applicable regulations promulgated by the Administrative Director concerning QME eligibility, the Administrative Director shall within 45 days send to the physician a Qualified Medical Evaluator certificate. The QME certificate shall be displayed in a conspicuous manner at the QME’s office location at all times during the period the QME is appointed by the Administrative Director to conduct evaluations.
(b) It shall be unlawful for any physician who has been terminated or suspended from the QME list or who has failed to pay the required QME fee to display a Qualified Medical Evaluator certificate.
§20. Time Periods.
(a) Within 45 days of receipt of an application for QME status, the Administrative Director shall either inform the applicant, in writing, that the application is complete and accepted for filing, or that the application is deficient and what specific information is required.
(b) Within 45 days of receipt of a completed application, the Administrative Director shall inform the applicant, in writing, of its decision to allow or not to allow the applicant to proceed to take the required QME competency examination as per Section 11(f) of Title 8 of the California Code of Regulations.
(c) Within 45 days of receipt of a completed application, the Administrative Director must inform the applicant, in writing, of its decision to grant or deny the application.
§26. QME Office Locations and Changes of Office Locations.
(a) Subject to the restriction in Labor Code section 139.2(h)(3)(B) of 10 offices for conducting comprehensive medical-legal evaluations, QMEs who perform comprehensive medical-legal evaluations at more than one physician’s office location shall be required to pay an additional $ 100 annually per additional office location. Each physician’s office listed with the Medical Director must be located within California, be identified by a street address and any other more specific location such as a suite or room number, and must contain the usual and customary equipment for the type of evaluation appropriate to the QME’s medical specialty or scope of practice.
(b) An office location shall be maintained by a QME at least 180 days from the date the Medical Unit lists the office as available to perform comprehensive medical-legal evaluations, except upon a showing of good cause to the Medical Director. (good cause definitions follow in this reg_
§34. Appointment Notification and Cancellation.
(a) Whenever an appointment for a comprehensive medical evaluation is made with a QME, the QME shall complete an appointment notification form by submitting the form in Section 110 (QME Appointment Notification Form) to the employee and the claims administrator, or if none the employer, within 5 business days of the date the appointment was made. (In a represented case, a copy of the completed form shall also be sent to the attorney who represents each party, if known.)
Failure to comply with this requirement shall constitute grounds for denial of reappointment under section 51 of Title 8 of the California Code of Regulations.
(b) The QME shall schedule an appointment for the first comprehensive medical-legal examination which shall be conducted at a medical office listed on the panel selection form or any office listed with the Medical Director. Any subsequent evaluation appointments may be performed at another medical office of the selected QME if it is listed with the Medical Director and is within a reasonable geographic distance from the injured worker’s residence.
(c) The QME shall include within the notification whether a Certified Interpreter is required and specify the language.
(d) An evaluator, whether an AME or QME, shall not cancel a scheduled appointment less than six (6) business days prior to the appointment date, except for good cause. Whenever an evaluator cancels a scheduled appointment, the evaluator shall advise the parties in writing of the reason for the cancellation. [[The Appeals Board shall retain jurisdiction to resolve disputes among the parties regarding whether an appointment cancellation pursuant to this subdivision was for good cause. / The Administrative Director shall retain jurisdiction to take appropriate disciplinary action against any QME for violations of this section. – concurrent JX.]]
(e) A QME or AME who cancels a scheduled appointment shall reschedule the appointment within sixty (60) calendar days of the date of the cancellation, unless the parties agree in writing to accept an appointment beyond the sixty (60) day limit.
(f) Failure to receive relevant medical records, as provided in section 35 of Title 8 of the California Code of Regulations and section 4062.3 of the Labor Code, prior to a scheduled appointment shall not constitute good cause under this section for the evaluator to cancel the appointment, unless the evaluator is a psychiatrist or psychologist performing an evaluation regarding a disputed injury to the psyche who states in the evaluation report that receipt of relevant medical records prior to the evaluation was necessary to conduct a full and fair evaluation.
(h) An appointment scheduled with an evaluator, whether an AME, Agreed Panel QME or QME shall not be cancelled or rescheduled by a party or the party’s attorney less than six (6) business days before the appointment date, except for good cause. The cancellation shall be made in writing, state the reason for the cancellation and be served on the opposing party. Oral cancellations shall be followed with a written confirming letter that is faxed or mailed by first class U.S. mail within twenty four hours of the verbal cancellation and that complies with this section. An injured worker shall not be liable for any missed appointment fee whenever an appointment is cancelled for good cause. The Appeals Board shall retain jurisdiction to resolve disputes regarding whether an appointment cancellation by a party pursuant to this subdivision was for good cause.
(i) The date of cancellation shall be determined from the date of postmark, if mailed, or from the facsimile receipt date as shown on the recipient’s fax copy.
§35. Exchange of Information and Ex Parte Communications.
(a) The claims administrator, or if none the employer, shall provide, and the injured worker may provide, the following information to the evaluator, whether an AME, Agreed panel QME or QME:
(1) All records prepared or maintained by the employee’s treating physician or physicians;
(2) Other medical records, including any previous treatment records or information, which are relevant to determination of the medical issue(s) in dispute;
(3) A letter outlining the medical determination of the primary treating physician or the compensability issue(s) that the evaluator is requested to address in the evaluation, which shall be served on the opposing party no less than 20 days in advance of the evaluation; …
(5) Non-medical records, including films and videotapes, which are relevant to determination of medical issue(s) in dispute, after compliance with subdivision 35(c) of Title 8 of the California Code of Regulations.
(b)(1) Except as expressly provided in Labor Code section 4062.3(f) concerning communications with an agreed medical evaluator, all communications by the parties with the evaluator shall be in writing and sent simultaneously to the opposing party when sent to the medical evaluator, except as otherwise provided in subdivisions (c), (k) and ( l ) of this section. Labor Code section 4062.3(f) allows oral or written communications with an AME physician or the physician’s staff relative to nonsubstantive matters such as the scheduling of appointments, missed appointments, the furnishing of records and reports, and the availability of the report, unless the appeals board has made a specific finding of an impermissible ex parte communication.
(2) Represented parties who have selected an Agreed Medical Evaluator or an Agreed Panel QME shall, as part of their agreement, agree on what information is to be provided to the AME or the Agreed Panel QME, respectively.
(c) At least twenty (20) days before the information is to be provided to the evaluator, the party providing such medical and non-medical reports and information shall serve it on the opposing party. Mental health records that are subject to the protections of Health and Safety Code section 123115(b) shall not be served directly on the injured employee, but may be provided to a designated health care provider as provided in section 123115(b)(2), and the injured employee shall be notified in writing of this option for each such record to be provided to the evaluator. In both unrepresented and represented cases the claims administrator shall attach a log to the front of the records and information being sent to the opposing party that identifies each record or other information to be sent to the evaluator and lists each item in the order it is attached to or appears on the log. In a represented case, the injured worker’s attorney shall do the same for any records or other information to be sent to the evaluator directly from the attorney’s office, if any. The claims administrator, or if none the employer, shall include a cover letter or other document when providing such information to the employee which shall clearly and conspicuously include the following language: “Please look carefully at the enclosed information. It may be used by the doctor who is evaluating your medical condition as it relates to your workers’ compensation claim. If you do not want the doctor to see this information, you must let me know within 10 days.”
(d) If the opposing party objects within 10 days to any non-medical records or information proposed to be sent to an evaluator, those records and that information shall not be provided to the evaluator unless so ordered by a Workers’ Compensation Administrative Law Judge.
(e) In no event shall any party forward to the evaluator: (1) any medical/legal report which has been rejected by a party as untimely pursuant to Labor Code section 4062.5; (2) any evaluation or consulting report written by any physician other than a treating physician, the primary treating physician or secondary physician, or an evaluator through the medical-legal process in Labor Code sections 4060 through 4062, that addresses permanent impairment, permanent disability or apportionment under California workers’ compensation laws, unless that physician’s report has first been ruled admissible by a Workers’ Compensation Administrative Law Judge; or (3) any medical report or record or other information or thing which has been stricken, or found inadequate or inadmissible by a Workers’ Compensation Administrative Law Judge, or which otherwise has been deemed inadmissible to the evaluator as a matter of law…
(g) Copies of all records being sent to the evaluator shall be sent to all parties except as otherwise provided in section (d) and (e). Failure to do so shall constitute ex parte communication within the meaning of subdivision (k) below by the party transmitting the information to the evaluator….
(i) In the event that a party fails to provide to the evaluator any relevant medical record which the evaluator deems necessary to perform a comprehensive medical-legal evaluation, the evaluator may contact the treating physician or other health care provider, to obtain such record(s). If the party fails to provide relevant medical records within 10 days after the date of the evaluation, and the evaluator is unable to obtain the records, the evaluator shall complete and serve the report to comply with the statutory time frames under section 38 of Title 8 of the California Code of Regulations. The evaluator shall note in the report that the records were not received within the required time period. Upon request by a party, or the Appeals Board, the evaluator shall complete a supplemental evaluation when the relevant medical records are received. For a supplemental report the evaluator need not conduct an additional physical examination of the employee if the evaluator believes a review of the additional records is sufficient.
(j) The evaluator and the employee’s treating physician(s) may consult as necessary to produce a complete and accurate report. The evaluator shall note within the report new or additional information received from the treating physician.
(k) The Appeals Board shall retain jurisdiction in all cases to determine disputes arising from objections and whether ex parte contact in violation of Labor Code section 4062.3 or this section of Title 8 of the California Code of Regulations has occurred. If any party communicates with an evaluator in violation of Labor Code section 4062.3, the Medical Director shall provide the aggrieved party with a new panel in which to select a new QME or the aggrieved party may elect to proceed with the original evaluator. Oral or written communications by the employee, or if the employee is deceased by the employee’s dependent, made in the course of the examination or made at the request of the evaluator in connection with the examination shall not provide grounds for a new evaluator unless the Appeals Board has made a specific finding of an impermissible ex parte communication.
§35.5. Compliance by AMEs and QMEs with Administrative Director Evaluation and Reporting Guidelines.
(a) Each evaluation examination and report completed pursuant to Labor Code sections 4060, 4061, 4062, 4062.1, 4062.2, 4064, 4067 or 5703.5 shall be performed in compliance with all appropriate evaluation procedures pursuant to this Chapter.
(b) Each reporting evaluator shall state in the body of the comprehensive medical-legal report the date the examination was completed and the street address at which the examination was performed. If the evaluator signs the report on any date other than the date the examination was completed, the evaluator shall enter the date the report is signed next to or near the signature on the report.
(c)(1) The evaluator shall address all contested medical issues arising from all injuries reported on one or more claim forms prior to the date of the employee’s appointment with the medical evaluator that are issues within the evaluator’s scope of practice and areas of clinical competence. The reporting evaluator shall attempt to address each question raised by each party in the issue cover letter sent to the evaluator as provided in subdivision 35(a)(3).
(2) If the evaluator declares the injured worker permanent and stationary for the body part evaluated and the evaluator finds injury has caused permanent partial disability, the evaluator shall complete the Physician’s Report of Permanent and Stationary Status and Work Capacity (DWC-AD Form 10133.36) and serve it on the claims administrator together with the medical report.
(d) At the evaluator’s earliest opportunity and no later than the date the report is served, the evaluator shall advise the parties in writing of any disputed medical issues outside of the evaluator’s scope of practice and area of clinical competency in order that the parties may initiate the process for obtaining an additional evaluation pursuant to section 4062.1 or 4062.2 of the Labor Code and these regulations in another specialty. In the case of an Agreed Panel QME or a panel QME, the evaluator shall send a copy of the written notification provided to the parties to the Medical Director at the same time…
(f) …[W]henever a party is legally entitled to depose the evaluator, the evaluator shall make himself or herself available for deposition within at least one hundred twenty (120) days of the notice of deposition and, upon the request of the unrepresented injured worker and whenever consistent with Labor Code section 5710, the deposition shall be held at the location at which the evaluation examination was performed, or at a facility or office chosen by the deposing party that is not more than 20 miles from the location of the evaluation examination.
(g)…(2) For any evaluation performed on or after July 1, 2013, and regardless of the date of injury, an Agreed Medical Evaluator or Qualified Medical Evaluator shall not provide an opinion on any disputed medical treatment issue, but shall provide an opinion about whether the injured worker will need future medical care to cure or relieve the effects of an industrial injury.
§36. Service of Comprehensive Medical-Legal Evaluation Reports …Including …Under Labor Code Section 4061.
(a) (1) Whenever an injured worker is represented by an attorney, the evaluator shall serve each comprehensive medical-legal evaluation report, follow-up comprehensive medical-legal evaluation report and supplemental evaluation report on the injured worker, his or her attorney and on the claims administrator, or if none the employer, by completing QME Form 122 (AME or QME Declaration of Service of Medical-Legal Report Form)(See, 8 Cal. Code Regs. § 122) and attaching QME Form 122 to the report, unless section 36.5 of Title 8 of the California Code of Regulations applies.
(2) If applicable in a claim involving disputed injury to the psyche, the evaluator shall comply with the requirements of section 36.5 of Title 8 of the California Code of Regulations (Service of Comprehensive Medical-Legal Report in Claims of Injury to the Psyche)
(b) (1) Whenever an injured worker is not represented by an attorney, the Qualified Medical Evaluator shall serve each comprehensive medical-legal evaluation report, follow-up evaluation report or supplemental report that addresses only disputed issues outside of the scope of Labor Code section 4061, by completing the questions and declaration of service on the QME Form 111 (QME Findings Summary Form) (See, 8 Cal. Code Regs. § 111), and by serving the report with the QME Form 111 attached, on the injured worker and the claims administrator, or if none on the employer, unless section 36.5 of Title 8 of the California Code of Regulations applies.
(2) If applicable in a claim involving disputed injury to the psyche, the evaluator shall comply with the requirements of section 36.5 of Title 8 of the California Code of Regulations (Service of Comprehensive Medical-Legal Report in Claims of Injury to the Psyche)
(c) (1) Whenever the evaluator is serving a medical-legal evaluation report that addresses or describes findings and conclusions pertaining to permanent impairment, permanent disability or apportionment of an unrepresented injured worker, the evaluator shall serve the following documents:
A. the evaluation report with a separator sheet, DWC-CA Form 10232.2
B. the completed QME Form 111 (QME Findings Summary Form) with a separator sheet, DWC-CA Form 10232.2
C. the DWC-AD Form 100 (DEU) (Employee’s Disability Questionnaire) with a separator sheet, DWC-CA Form 10232.2
D. the DWC-AD Form 101 (DEU) (Request for Summary Rating Determination of Qualified Medical Evaluator’s Report), with a separator sheet, DWC-CA Form 10232.2; and
E. A document cover sheet, DWC-CA Form 10232.1
The documents listed above shall be simultaneously served on the local DEU office, at the same time as serving the report on the claims administrator, or if none the employer, and on the unrepresented employee within the time frames specified in section 38 of Title 8 of the California Code of Regulations, unless section 36.5 of Title 8 of the California Code of Regulations applies.
(2) If applicable, in cases involving disputed injury to the psyche, the evaluator shall follow the procedures described in section 36.5 of Title 8 of the California Code of Regulations (Service of Comprehensive Medical-Legal Report in Claims of Injury to the Psyche)
(d) If an evaluation report is completed for an unrepresented employee, in which the QME determines that the employee’s condition has not become permanent and stationary as of the date of the evaluation, the parties shall request any further evaluation from the same QME if the QME is currently an active QME and available at the time of the request for the additional evaluation. …. In no event shall a physician who is not a QME or no longer a QME perform a follow up evaluation on an unrepresented injured worker.
(e) Except as provided in Section 37 concerning a request for factual correction, after a Qualified Medical Evaluator has served a comprehensive medical-legal report that finds and describes permanent impairment, permanent disability or apportionment in the case of an unrepresented injured worker, the QME shall not issue any supplemental report on any of those issues in response to a party’s request until after the Disability Evaluation Unit has issued an initial summary rating report, or unless the evaluator is otherwise directed to issue a supplemental report by the Disability Evaluation Unit, by the Administrative Director or by a Workers’ Compensation Administrative Law Judge. ..
§36.5. Service of Comprehensive Medical/Legal Report in Claims of Injury to the Psyche.
(a) For any evaluation involving a claimed or disputed injury to the psyche, the injured worker shall be advised by the evaluator that the employee’s copy of the comprehensive medical-legal report, and any follow up or supplemental reports, from the evaluation may be served either directly on the injured worker or instead on a physician designated in writing by the injured worker prior to leaving the evaluator’s office, for the purpose of reviewing and discussing the evaluation report with the injured worker. The evaluator shall explain that the designated physician may be but need not be the injured worker’s primary treating physician in the workers’ compensation claim and that the employer will be responsible for payment for one office visit with the designated physician for this purpose.
(b) Whenever injury to the psyche is claimed and in the course of the evaluation, the evaluator makes a determination pursuant to Health and Safety Code section 123115(b) that there is a substantial risk of significant adverse or detrimental medical consequences to the injured worker from seeing or receiving a copy of part or all of evaluation report which is a mental health record, the evaluator shall do all of the following:
(1) Complete QME Form 121 (Declaration Regarding Protection of Mental Health Record);
(2) Advise the injured worker that the determination under Health and Safety Code 123115(b) has been made regarding the evaluation report as a mental health record and that the evaluator only may serve the injured worker
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s copy of the evaluation report on a person who is a licensed physician, as defined in Labor Code section 3209.3, whose name the injured worker may designate in writing prior to leaving the evaluator
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s office, or on the employee
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s attorney, if any;
(3) Permit inspection and copying of the mental health record(s) subject to the Health and Safety Code section 123115(b) determination, only by a licensed physician as defined in Labor Code section 3209.3 or another health care provider as defined in Health and Safety Code section 123105(a);
(4) Complete the QME Form 121 and enter the name and address of the physician designated in writing by the injured worker on this form;
(5) Attach a completed copy of QME Form 121 (Declaration Regarding Protection of Mental Health Record) to the copy of the evaluation report in the injured worker
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s medical or medical-legal file;
(6) Serve the completed comprehensive medical-legal evaluation report, follow-up medical-legal report or supplemental medical-legal report(s) subject to the provisions of this section, with the completed QME Form 121 (Declaration Regarding Protection of Mental Health Record) attached, on the licensed physician designated by the injured worker on QME Form 121, and on the claims administrator, and on each party
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s attorney, if any
…
In the event the injured worker designates a physician on QME Form 121 other than the current primary treating physician in his or her workers
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compensation claim, the evaluator shall also serve a copy of the report with the QME Form 121 attached on the primary treating physician;
(7) Whenever the report addresses any permanent impairment, permanent disability or apportionment and the injured worker is not represented by an attorney, a copy of the report with the completed QME Form 121 attached shall also be served on the appropriate office of the Disability Evaluation Unit, along with the QME Form 111 (QME
’
s Findings Summary Form), and DWC-AD form 100 (DEU) and DWC-AD form 101 (DEU) (Request for Summary Rating Determination of Qualified Medical Evaluator
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s Report), with the document cover sheet, DWC-CA form 10232.1, and separator sheet, DWC-CA form 10232.2 , as required by Title 8, California Code of Regulations section 10160(d)(4);
(8) Whenever the report addresses permanent impairment, permanent disability or apportionment and the injured worker is represented by an attorney, a copy of the report with the completed QME Form 121 attached shall be served with QME Form 122 (AME or QME Declaration of Service of Medical-Legal Report) on the physician designated by the injured worker, the injured worker
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s attorney and on the claims administrator
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s attorney, or if none on the claims administrator
…
(f) Whenever the injured worker advises the evaluator that he or she prefers to have the evaluation report served on a designated physician as provided in subdivision 36.5(b) above, and the evaluator does not make a determination pursuant to Health and Safety Code section 123115(b), the evaluator shall provide QME Form 120 (Voluntary Directive for Alternate Service of Medical-Legal Report) to the injured worker and shall request the injured worker to complete the form before leaving the evaluator’s office.
(g) Upon receipt by the evaluator of a QME Form 120 completed by the injured worker, the evaluator shall attach the original executed QME Form 120 to the original medical-legal report for service on the claims administrator, or if none on the employer. The evaluator shall serve the evaluation report with QME Form 120 attached by completing the questions and the declaration of proof of service on QME Form 111 (Qualified Medical Evaluator’s Findings Summary Form) . In the case of an unrepresented injured worker, the evaluator shall serve the report with the required forms as provided in subdivision 36.5(b)(7) of Title 8 of the California Code of Regulations. In the case of a represented injured worker, the evaluator shall serve the report with QME Form 120 attached, by completing the declaration of service on QME Form 122 (AME or QME Declaration of Service of Medical-Legal Report) and serving it with the report.
(h) Whenever an evaluation report is being served on a designated physician with QME Form 120 (Voluntary Directive for Alternate Service of Medical-Legal Report) , the evaluator shall serve two copies of the medical-legal report with the QME Form 120 attached on the physician designated on the form by the injured worker, at the same time as serving the copies of the medical-legal report on the claims administrator, or if none on the employer, and on the injured worker’s attorney if any. ..
(k) In the event the injured worker refuses or fails to designate a physician in writing to be listed on either QME Form 120 or QME Form 121, the evaluator shall serve the report as appropriate under section 36 or section 36.5, and within the time periods under section 38, of Title 8 of the California Code of Regulations, except that the injured worker’s copy of the report which is subject to a finding under Health and Safety Code § 123115(b) shall then be served only on the injured worker’s attorney, if represented, or if not represented on the injured worker’s primary treating physician.
§38. Medical Evaluation Time Frames; Extensions for QMEs and AMEs.
(a) The time frame for an initial or a follow-up comprehensive medical-legal evaluation report to be prepared and submitted shall not exceed thirty (30) days after the QME, Agreed Panel QME or AME has seen the employee or otherwise commenced the comprehensive medical-legal evaluation procedure.
(b) If an evaluator fails to prepare and serve the initial or follow-up comprehensive medical-legal evaluation report within thirty (30) days and the evaluator has failed to obtain approval from the Medical Director for an extension of time pursuant to this section, the employee or the employer may request a QME replacement pursuant to section 31.5 of Title 8 of the California Code of Regulations. Neither the employee nor the employer shall have any liability for payment for the medical evaluation which was not completed within the timeframes required under this section unless the employee and the employer each waive the right to a new evaluation and elect to accept the original evaluation, in writing or by signing and returning to the Medical Director either QME Form 113 (Notice of Denial of Request For Time Extension) or QME Form 116 (Notice of Late QME/AME Report - No Extension Requested)
(c) All requests by an evaluator for extensions of time shall be made on form 112 (QME/AME Time Frame Extension Request). If the evaluation will not be completed on the original due date, the evaluator may request an extension from the Medical Director, not to exceed an additional 30 days. An extension of the time for completing the report shall be approved, as follows:
(1) When the evaluator has not received test results or the report of a consulting physician, necessary to address all disputed medical issues in time to meet the initial 30-day deadline, an extension of up to thirty (30) days shall be granted;
(2) When the evaluator has good cause, as defined in Labor Code section 139.2(j)(1)(B), an extension of fifteen (15) days shall be granted.
(d) Not later than 5 days before the initial 30-day period to complete and serve the report expires, the evaluator shall notify the Medical Director, the employee and the claims administrator, or if none, the employer, of the request for an extension by use of QME Form 112 (QME/AME Time Extension Request)
(e) The Medical Director shall notify the requesting evaluator and the parties of the decision on the extension request by completion of the box at the bottom of QME Form 112 (QME/AME Time Frame Extension Request)…
(g) Good cause, as defined in Labor Code section 139.2(j)(1)(B) and section 38(b)(2) of Title 8 of the California Code of Regulations, means:
(1) medical emergencies of the evaluator or the evaluator’s family;
(2) death in the evaluator’s family;
(3) natural disasters or other community catastrophes that interrupt the operation of the evaluator’s office operations;
(h) Extensions shall not be granted because relevant medical information/records (including Disability Evaluation Form 101 (Request for Summary Determination of Qualified Medical Evaluator’s Report)) have not been received. The evaluator shall complete the report based on the information available and state that the opinions and/or conclusions may or may not change after review of the relevant medical information/records.
(i) Except as provided in Section 37 with respect to a request for factual correction, the time frame for supplemental reports shall be no more than sixty (60) days from the date of a written or electronically transmitted request to the physician by a party. The request for a supplemental report, except for requests for factual correction, shall be accompanied by any new medical records that were unavailable to the evaluator at the time of the original evaluation and which were properly served on the opposing party as required by Labor Code section 4062.3. An extension of the sixty (60) day time frame for completing the supplemental report, of no more than thirty (30) days, may be agreed to by the parties without the need to request an extension from the Medical Director.
(j) Evaluators requesting time extensions will be monitored and advised by the Medical Director when such a request appears unreasonable or excessive. Failure to comply with this section may constitute grounds for denial of the QME’s request for reappointment pursuant to section 51 of Title 8 of the California Code of Regulations.
§39.5. Retention of Records by QMEs.
(a) All QMEs shall retain a copy of all comprehensive medical-legal reports completed by the QME for a period of five years from the date of each evaluation report. A QME may satisfy this requirement by retaining only an electronic copy of the report, as long as the electronic copy retained is a true and correct copy of the original, showing the QME signature, that was served on the parties. Upon written request, a QME is required to return original radiological films, imaging studies and original medical records to the person who supplied the original records to the QME or to the injured worker.
(b) An evaluator shall submit all comprehensive medical/legal reports performed as a QME under this article to the Medical Director upon request for a review by the Medical Director. Failure to submit evaluations upon request by the Medical Director may constitute grounds for disciplinary action pursuant to Section 60.
§40. Disclosure Requirements: Injured Workers.
(a) An evaluator selected from a QME panel shall advise an injured worker prior to or at the time of the actual evaluation of the following:
(1) That he or she is entitled to ask the evaluator and the evaluator shall promptly answer questions about any matter concerning the evaluation process
…
(2) That subject to section 41(g), the injured worker may discontinue the evaluation based on good cause. Good cause includes: (A) discriminatory conduct by the evaluator towards the worker based on race, sex, national origin, religion, or sexual preference, (B) abusive, hostile or rude behavior including behavior that clearly demonstrates a bias against injured workers, and (C) instances where the evaluator requests the worker to submit to an unnecessary exam or procedure.
(b) When required as a condition of probation by the Administrative Director or his/her licensing authority, the QME shall disclose his/her probationary status. … If at that time, the injured worker declines to proceed with the evaluation, such termination shall be considered by the Administrative Director to have occurred for good cause.
(c) If the injured worker declines to ask any questions relating to the evaluation procedure as set forth in section 40(a), and does not otherwise object on the grounds of good cause to the exam proceedings under section 41(a) during the exam itself, the injured worker shall have no right to object to the QME comprehensive medical-legal evaluation based on a violation of this section.
§41. Ethical Requirements.
(a) All QMEs, regardless of whether the injured worker is represented by an attorney, shall:
(1) Maintain a clean, professional physician
’
s office (as defined in section 1(y) at all times which shall contain functioning medical instruments and equipment appropriate to conducting the evaluation within the physician
’
s scope of practice and a functioning business office phone
…
.
(2) Schedule all appointments for comprehensive medical-legal evaluations without regard to whether a worker is unrepresented or represented by an attorney. A QME shall not refuse to schedule an appointment with an injured worker solely because the worker is not represented by an attorney or because a promise to reimburse or reimbursement is not made prior to the evaluation.
(3) Not request the employee to submit to an unnecessary exam or procedure.
(4) Refrain from treating or soliciting to provide medical treatment, medical supplies or medical devices to the injured worker.
(5) Communicate with the injured worker in a respectful, courteous and professional manner.
(6) Refrain from violating CCR section 41.5 (Conflicts of Interests).
(7) Refrain from unilaterally rescheduling a panel QME examination more than two times in the same case.
(8) Refrain from cancelling a QME examination less than six (6) business days from the date the exam is scheduled without good cause and without providing a new examination date within thirty (30) calendar days of the date of cancellation.
(b) Evaluators selected from a QME panel provided by the Administrative Director shall not engage in ex parte communication in violation of Labor Code section 4062.3.
(c) All QMEs, regardless of whether the injured worker is represented by an attorney, shall with respect to his or her comprehensive medical-legal evaluation:
(1) Refuse any compensation from any source contingent upon writing an opinion that in any way could be construed as unfavorable to a party to the case.
(2) Review all available relevant medical and non-medical records and/or facts necessary for an accurate and objective assessment of the contested medical issues in an injured worker
’
s case before generating a written report. The report must list and summarize all medical and non-medical records reviewed as part of the evaluation.
(3) Render expert opinions or conclusions without regard to an injured worker
’
s race, sex, national origin, religion or sexual preference.
(4) Render expert opinions or conclusions only on issues which the evaluator has adequate qualifications, education, and training. All conclusions shall be based on the facts and on the evaluator
’
s training and specialty-based knowledge and shall be without bias either for or against the injured worker or the claims administrator, or if none the employer.
(5) Present a report that addresses all relevant and contested medical issues as presented on one or more claim forms, is ratable by the DEU, if applicable, and complies with all relevant guidelines of the Administrative Director.
(6) Date the report on the date it is completed and ready for signature and service on the parties
…
.
(7) Write all portions of the report that contain discussion of medical issues, medical research used as the basis for medical determinations, and medical conclusions made by the evaluator. In the event more than one evaluator signs a single report, each signing physician shall clearly state those parts of the employee evaluation examination performed and the portions of the report discussion and conclusion drafted by the signing evaluator. Where a consultation report is obtained by an evaluator from a physician in a different specialty, the consultation report shall be incorporated by reference into the final report and appended to the referring QME
’
s report.
(8) Serve the report as provided in these regulations at the same time on the employee and the claims administrator, or if none the employer, and on each of their attorneys, respectively.
(d) All aspects of all physical and/or psychological comprehensive medical-legal evaluations, including history taking, shall be directly related to contested medical issues as presented by any party or addressed in the reports of treating physician(s). No evaluator shall engage in any physical contact with the injured worker which is unnecessary to complete the examination.
(e) No physician certified by the Administrative Director as a QME, or his or her agent, shall contact an evaluator for the purpose of influencing that evaluator’s opinions or conclusions in any comprehensive medical-legal evaluation or report.
(f) No evaluator shall schedule appointments to the extent that any injured worker will be required to wait for more than one hour at the evaluator’s office prior to being seen for the previously agreed upon appointment time for an evaluation. An injured worker who is not seen by the evaluator within one hour may terminate the exam and request a replacement evaluator from the Administrative Director. No party shall be liable for the terminated exam. The evaluator may explain any reasons for the delay to the injured worker and, provided both parties agree, the evaluation may proceed or be rescheduled for a later date. If the evaluation is rescheduled, the evaluator shall provide notice of the new date of the evaluation to the parties within 5 business days after rescheduling the appointment….
(h) Nothing in this section shall require an evaluator to undertake or continue a comprehensive medical-legal evaluation where the injured worker or his/her representative uses abusive language towards the evaluator or evaluator’s staff or deliberately attempts to disrupt the operation of the evaluator’s office in any way. The evaluator shall state under penalty of perjury, the facts supporting the termination of the evaluation process. Upon request, the Medical Director shall investigate the facts and make a final determination of the issue(s).
(i) Nothing in this section shall require an evaluator selected from a panel to undertake or continue a comprehensive medical-legal evaluation where the injured worker is intoxicated or under the influence of any medication which impairs the injured worker’s ability to participate in the evaluation process. The evaluator shall state under penalty of perjury, the facts supporting the termination of the evaluation process. Upon request, the Medical Director shall investigate the facts and make a final determination of the issue(s).
§41.5. Conflicts of Interest by Medical Evaluators.
a) 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 the Labor Code or the regulations of the Administrative Director or of the Workers’ Compensation Appeals Board.
(b) A conflict with the duties of an evaluator as used in Labor Code section 139.2(o) 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.
(c) The persons or entities with whom a disqualifying conflict of interest can exist are:
(1) The injured worker, or his or her attorney;
(2) The employer, or the employer
’
s attorney;
(3) The claims adjuster or insurer or third party administrator, or their attorney, respectively;
(4) Any primary treating physician or secondary physician for the employee, if the treatment provided by that physician is disputed in the case;
(5) The utilization review physician reviewer or expert reviewer, or utilization review organization, only if the opinion of that reviewer or that utilization review organization is disputed in the case;
(6) The surgical center in which the injured worker had, or is proposed to be used to have, surgery, only if the need for surgery is disputed in the case.
(7) Other purveyor of medical goods or medical services, only if the medical necessity for using such goods or services is in dispute in the case.
(d) “Disqualifying Conflict of Interest” means the evaluator has any of the following relationships or interests with a person or entity listed in subdivision 41.5(c):
(1) A familial relationship of parent, child, grandparent, grandchild, sibling, uncle, aunt, nephew, niece, spouse, financee or cohabitant;
(2) A significant disqualifying financial interest
…
(3) A professional affiliation which means the evaluator performs services in the same medical group or other business entity comprised of medical evaluators who specialize in workers
’
compensation medical-legal evaluations;
(4) Any other relationship or interest not addressed by subdivisions (d)(1) through (d)(3) which would cause a person aware of the facts to reasonably entertain a doubt that the evaluator would be able to act with integrity and impartiality.
(e) An Agreed Medical Evaluator or a Qualified Medical Evaluator may disqualify himself or herself on the basis of a conflict of interest pursuant to this section whenever the evaluator has a relationship with a person or entity in a specific case, including doctor-patient, familial, financial or professional, that causes the evaluator to decide it would be unethical to perform a comprehensive medical-legal evaluation examination or to write a report in the case.
(f) An Agreed Medical Evaluator or Qualified Medical Evaluator who knows, or should know, that he or she has a disqualifying conflict of interest with any person or entity listed in subdivision 41.5(c), that also is involved in the specific workers’ compensation claim identified to the evaluator, shall send written notification to the injured worker and the claims administrator, or if none the employer, or their respective attorneys if any, within five (5) business days of the evaluator becoming aware of the conflict. The written notice shall include, at a minimum: 1) disclosure that a disqualifying conflict of interest exists; 2) the person or entity with whom the conflict arises; and 3) the category of conflict, such as familial, significant financial, or other type of ethical conflict. Whenever the evaluator declines to perform an evaluation due to disqualifying himself or herself pursuant to subdivision 41.5(e), the parties shall be entitled to a replacement QME …. Whenever the evaluator notifies the parties of a conflict without stating that he or she declines to perform the evaluation, the parties shall follow the procedures set out in section 41.6 of Title 8 of the California Code of Regulations. In any case in which the injured worker is not represented by an attorney, the evaluator shall fax a copy of the notice of conflict to the Medical Unit of the Division of Workers’ Compensation at the same time it is sent to the parties.
(g) Any injured worker or claims administrator or if none the employer, including his or her attorney respectively, who knows of, or becomes aware of, a potential disqualifying conflict of interest, …shall notify the selected evaluator in writing at the earliest opportunity and no later than within five (5) business days of becoming aware of the potential conflict, to enable the evaluator to determine whether the disqualifying conflict exists. …The evaluator shall review the information provided and advise the parties in writing within five (5) business days of receipt of the notice whether the evaluator has a conflict of interest as specified in this section.
§41.7. Gifts to Medical Evaluators.
(a) No physician reporting as an Agreed Medical Evaluator or a Qualified Medical Evaluator shall accept gifts that have a total fair market value in the aggregate of three hundred sixty dollars ($ 360) or more, from any single source that handles California workers’ compensation matters, in the course of any consecutive twelve months. The sources include, but are not limited to, one or more attorneys, physicians, employers, claims administrators, medical or health care or insurance or utilization review business entities. …
(b) For the purposes of this section, “Gift” means any payment to the extent that consideration of equal or greater value is not received. It includes any rebate or discount in the price of anything of value, unless the rebate or discount is also made in the regular course of business to members of the public, and any loan, forgiveness or other thing of value having a fair market value in excess of $ 360 in the aggregate…
(d) A Qualified Medical Evaluator who violates any portion of this section shall be subject to disciplinary action pursuant to section 60 et seq of these regulations.
§§49.2 - 49.9 Minimum Time Guidelines
Neuromusculoskeletal Evaluation - 20 min
Cardiovascular Evaluation - 30 min
Pulmonary Evaluation - 30 min
Psychiatric Evaluation - 1 hour
Other Evaluation - 30 min
§50. Reappointment: Requirements and Application Form.
(a) … For all physicians, applications for reappointment shall include a Reappointment Application Form in §104, and the appropriate fee under §17. The reappointment application and the appropriate fee shall be filed at the Administrative Director’s headquarters office listed on the reappointment form.
(b) Any Reappointment Application Form may be rejected if it is incomplete or does not contain the required supporting documentation listed in §11 and on the Reappointment Application Form. As part of the approval of the Reappointment Application Form, the Administrative Director shall verify that the QME has complied with all requirements under this Article.
(c) When a QME applies for reappointment, he or she shall submit a statement signed under penalty of perjury:
(1) attesting that he or she has completed the applicable QME continuing education requirement; and
(2) listing the dates, locations, and titles of the continuing education programs and the names of the providers of those programs which he or she has taken to meet the requirement of Labor Code section 139.2(d)(3), as well as the number of hours of attendance at each program.
…
and
(3) attesting that the physician has accurately reported on the QME SFI Form 124
…
and
(4) attesting that the physician
’
s license to practice as a physician
…
is neither restricted nor encumbered by suspension or probation, nor has the physician been convicted of a misdemeanor or felony related to the physician
’
s practice or a crime of moral turpitude, and that the physician will notify the Administrative Director if the physician
’
s license to practice is subsequently suspended or placed on probation or if the physician is convicted of a misdemeanor or felony related to the physician
’
s practice or of a crime of moral turpitude; and
(5) attesting that the physician shall abide by all regulations of the Administrative Director and shall refrain from making referrals in violation of those regulations; and
(6) attesting that the physician has not performed a QME evaluation during a time when the physician was not appointed as a QME.
