QME testing Flashcards
(15 cards)
What California Labor Code section outlines the procedures for QME evaluations?
The California Labor Code section that outlines procedures for Qualified Medical Evaluator (QME) evaluations is primarily Labor Code § 4060–4068, with supporting regulations under Title 8 of the California Code of Regulations (CCR), sections 1–159.
Within how many days must a QME submit an initial evaluation report?
within 30 days per California Code of Regulations, Title 8, Section 38(h).
Which regulation specifies the required elements of a complete medical-legal report?
CCR Title 8 §10682 – Required Elements of a Comprehensive Medical-Legal Report
What is the maximum time allowed for a QME to reschedule an evaluation?
California Code of Regulations, Title 8, §41.5(a)
“If the QME is unable to schedule the appointment within 60 days of the date the appointment was originally scheduled, and the injured worker does not agree in writing to extend this time frame, the injured worker may request a replacement panel.”
What section of the Labor Code mandates apportionment of permanent disability?
Labor Code §4663:
Requires that permanent disability be apportioned between the industrial (work-related) and non-industrial causes. Physicians must determine what percentage of the disability was caused by the work injury versus other factors, such as prior injuries or preexisting conditions.
What must a QME include in their declaration of accuracy?
Required Language (per Labor Code §4628):
“I declare under penalty of perjury under the laws of the State of California that:
I personally took the history from the injured worker,
I personally examined the injured worker,
I personally reviewed and summarized the medical and non-medical records, and
I personally authored this report.
If I used any assistants, they are identified by name and function in this report.
I understand that failure to comply with Labor Code Section 4628 is grounds for denial of payment and may subject me to disciplinary action by the DWC Medical Unit.”
Can a QME communicate with the applicant attorney before the evaluation?
NO
California Labor Code §4062.3(e) strictly regulates communication with a QME:
“Ex parte communications with the medical evaluator selected from a panel are prohibited… All communications shall be in writing and shall be served on all parties.”
How many days does a party have to object to a treating physician’s report to preserve QME rights?
Under California Workers’ Compensation law, an injured worker has 10 days to object to a treatment recommendation made by their Primary Treating Physician (PTP) if they want to preserve their right to request a Qualified Medical Evaluator (QME) panel under Labor Code § 4062.
Here’s the timeline:
- When the injured worker receives a Request for Authorization (RFA) decision approving or modifying treatment, they must object within 10 days (calendar days, not business) from the date of receipt of the written treatment recommendation.
- If they do not object within 10 days, they waive their right to dispute the treatment decision through the QME process.
This 10-day rule is part of Labor Code § 4062(a) and related DWC regulations.
What are the three core components of a QME’s opinion on permanent disability?
Causation, apportionment, and impairment rating.
Who selects the specialty for a panel QME?
labor code 4062.1 and 4062.2(unrepresented/represented)
Unrepresented Injured Worker
If the injured worker is not represented by an attorney, the injured worker selects the QME specialty when requesting the panel using DWC Form 105.
- Represented Injured Worker
If the injured worker has legal representation, the parties jointly request a panel QME using DWC Form 106.
If they cannot agree on a specialty, the requesting party selects the specialty when filing the panel request. The other party can object, but the specialty initially selected is typically what the Division of Workers’ Compensation Medical Unit uses to generate the panel.
- Disputes Over Specialty
If there’s a disagreement about which specialty is appropriate (e.g., ortho vs. pain medicine), the parties may:
Litigate the issue before a Workers’ Compensation Judge (WCJ).
Or, one party may request the panel and the other party may file a motion to strike the panel or request a different one.
What form must be used to request a QME panel?
QME Form 105 (Unrepresented Worker)
Used when the injured worker does not have an attorney.
Either the claims administrator or the injured worker may submit this form.
The form must be submitted after a valid objection has been made under Labor Code §4060 (compensability), §4061 (permanent disability), or §4062 (treatment dispute).
- QME Form 106 (Represented Case)
Used when the injured worker has legal representation.
The request must be submitted jointly or with documentation showing an agreement couldn’t be reached on an Agreed Medical Evaluator (AME).
Under what conditions may a QME issue a supplemental report?
According to CCR §35(k), a QME may issue a supplemental report when:
New Medical Records Become Available
Relevant medical records, test results, or imaging studies that were not previously reviewed are submitted by either party.
Clarification is Requested
A party or the Workers’ Compensation Appeals Board (WCAB) requests clarification or further explanation of the original findings.
The request must be made in writing and served on all parties in compliance with Labor Code §4062.3(e).
Additional Issues Arise
New disputes or medical-legal issues arise that were not addressed in the original report, and the QME is still the designated evaluator for the case.
Court Orders or Stipulations
The WCAB or a judge may order a supplemental report to resolve factual or legal issues.
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What time frame is required for QME panel selection in a represented case?
Panel must be requested within 10 days of an objection, per LC §4062.2(b).
Can a QME address denied body parts?
Yes, the QME must evaluate all body parts in dispute or as requested, even if denied by the claims administrator.
What does CCR stand for in this context?
California Code of Regulations – governing administrative procedures in workers’ compensation.
