QME testing 7 Flashcards
(15 cards)
What does MMI stand for in workers’ compensation?
Maximum Medical Improvement – the point at which a condition is unlikely to improve with further treatment.
What is the significance of reaching MMI in a workers’ compensation claim?
It triggers the evaluation of permanent disability and ends temporary disability payments.
What does AOE/COE stand for?
Arising Out of Employment / Occurring in the Course of Employment – determines if injury is work-related.
What is temporary total disability (TTD)?
Wage replacement benefits paid when a worker cannot perform any job duties due to work injury.
What are valid reasons to place a patient on TTD?
Inability to work in any capacity due to objective medical findings, post-surgical recovery, or pending FCE.
What triggers a medical-legal dispute under California workers’ compensation?
A disagreement over diagnosis, causation, treatment, work restrictions, or permanent disability.
Who selects the QME specialty in a disputed body part case when parties cannot agree?
The DWC Medical Unit assigns the specialty based on the panel request.
What happens if a QME determines that a claimed body part is not industrially related?
That portion of the claim may be denied, and treatment/comp benefits may not be authorized for that region.
Can a QME render an opinion on denied body parts?
Yes. The QME must evaluate all body parts identified in the panel request and available medical records.
What is the threshold for an injury to qualify as compensable under AOE/COE?
There must be a reasonable medical probability that employment contributed to the injury.
How does the QME support a claim for compensability?
By documenting how the injury arose out of employment and providing medical rationale linking the condition to work.
Can emotional or psychological injuries be compensable under workers’ comp?
Yes, if work stress or traumatic events substantially contributed to the condition and criteria under Labor Code §3208.3 are met.
What is required for an injury to be presumed compensable after 90 days?
The employer failed to deny liability within 90 days of claim submission (Labor Code §5402(b)).
What is the role of a Functional Capacity Evaluation (FCE)?
To objectively assess a patient’s work capabilities and validate physical restrictions or limitations.
When might an FCE be recommended?
When there’s uncertainty about work restrictions, return-to-work status, or to support TTD/P&S decisions.
