QME Trove Flashcards
(906 cards)
1
Q
What was a significant reason workers’ compensation systems were established in the early twentieth century in the U.S.?
A
To prevent the need for employees to prove employer negligence in court
2
Q
What was the primary purpose of the Boynton Act of 1913?
A
To require most employers to provide workers’ compensation coverage
3
Q
Which act replaced the Boynton Act in 1917 and included provisions for considering an employee’s diminished ability to compete in the labor market?
A
The Workers’ Compensation Insurance and Safety Act
4
Q
What does the “No Fault” rule in the workers’ compensation system imply?
A
Employers are required to provide benefits regardless of who caused the injury, Employees cannot file for workers’ compensation if they were aware of the risks
5
Q
Under the “Historic Compromise,” what is one benefit that employees give up in exchange for prompt workers’ compensation benefits?
A
The right to file a civil suit for damages
6
Q
Which of the following is NOT a component of the “Historic Compromise” in the workers’ compensation system?
A
Unlimited Compensation
7
Q
What happens to workers’ compensation benefits if an injury results from the serious and willful misconduct of the employer?
A
Benefits are doubled
8
Q
What changes were introduced by the measures enacted in 2003 and 2004 regarding medical treatment?
A
Allowed employers to establish medical provider networks and limit certain treatments
9
Q
Which of the following is an exception to the “No Fault” rule under California workers’ compensation law?
A
Deliberately self-inflicted injuries
10
Q
What was one of the major changes introduced in 2013 to California’s workers’ compensation system?
A
Introduction of independent medical review for treatment disputes, Elimination of medical provider networks, Reducing the amount of compensation for temporary disabilities
11
Q
Which of the following individuals is NOT associated with the Department of Industrial Relations?
A
Jose Garcia,
12
Q
What is the primary mission of the Division of Workers’ Compensation (DWC)?
A
To minimize the adverse impact of work-related injuries on California employees and employers,
13
Q
Which unit within the DWC is responsible for conducting audits to ensure compliance with the Labor Code and DWC regulations?
A
Audit and Enforcement Unit,
14
Q
What does the Disability Evaluation Unit (DEU) primarily determine?
A
Permanent disability ratings,
15
Q
Which unit provides assistance to employees, employers, and other parties regarding rights and benefits under California’s workers’ compensation laws?
A
Information and Assistance (I&A) Unit,
16
Q
What is one function of the Workers’ Compensation Appeals Board (WCAB)?
A
Reviewing Petitions for Reconsideration of decisions made by Workers’ Compensation Administrative Law Judges,
17
Q
Which unit is responsible for overseeing medical provider networks and handling complaints against Qualified Medical Evaluators (QMEs)?
A
Medical Unit,
18
Q
What is the purpose of the Workers’ Compensation Information System (WCIS)?
A
To collect and manage electronic records from claims administrators,
19
Q
Which fund provides compensation when employers fail to pay workers’ compensation benefits and are illegally uninsured?
A
Uninsured Employers Benefits Trust Fund (UEBTF),
20
Q
What type of permanent disability ratings does the DEU prepare?
A
Formal, consultative, and summary,
21
Q
The Medical Unit under the DWC is involved in which of the following activities?
A
Certifying and overseeing medical provider networks (MPNs),
22
Q
Which unit is tasked with assisting in the resolution of disputes and complaints related to workers’ compensation claims?
A
Information and Assistance (I&A) Unit,
23
Q
Which fund provides additional compensation to workers who had a pre-existing disability that combined with a new injury to result in a permanent disability of at least 70%?
A
Subsequent Injuries Benefits Trust Fund (SIBTF)
24
Q
What role does the Audit and Enforcement Unit play in the workers’ compensation system?
A
It ensures that insurance companies and self-insured employers meet their obligations under the Labor Code,
24
25
Which unit is responsible for examining and appointing physicians to be Qualified Medical Evaluators (QMEs)?
Medical Unit,
26
What is the main function of the Legal Unit within the DWC?
To provide legal advice and representation for the DWC,
27
Which of the following is a responsibility of the Disability Evaluation Unit (DEU)?
Preparing permanent disability ratings for use in determining benefits
28
The Workers’ Compensation Appeals Board (WCAB) consists of how many commissioners?
Seven
29
Which unit handles disputes and complaints related to the Qualified Medical Evaluator (QME) process?
Medical Unit
30
What is the primary function of the Research Unit within the DWC?
To analyze and report on data related to the workers’ compensation system
31
Which unit is responsible for assisting injured workers with understanding their rights and benefits under California’s workers’ compensation laws?
Information and Assistance (I&A) Unit
32
What is the purpose of taking a complete occupational history?
To understand all jobs the worker has held, including hazards and protective equipment used
33
How is a specific injury defined in the context of workers' compensation?
An injury resulting from a single incident or exposure
34
What is the definition of first aid according to the Labor Code?
Any one-time treatment for minor injuries that do not require further medical care
35
What does the term "arising out of employment" (AOE) refer to?
The injury is directly related to the work environment or tasks
36
What is considered an aggravation of a pre-existing non-industrial condition?
An on-the-job incident that worsens a pre-existing condition
37
In the workers' compensation system, which of the following injuries is excluded from compensation?
Injuries resulting from alcohol or illegal substance use
38
When determining causation, which of the following is NOT a type of causation?
Recurrence
39
Why is the "date of injury" (DOI) important in a workers' compensation claim?
It determines the statute of limitations for filing a claim
40
What is required to prove that an injury is work-related?
Work activities contributed to the injury to a significant degree
41
How is a cumulative injury defined in the context of workers' compensation?
An injury that results from repetitive trauma over time
42
In which scenario would a physician’s report NOT lead to the establishment of a compensable injury?
The injury was caused by the employee’s use of illegal substances
43
What does "occurring in the course of employment" (COE) imply?
The injury occurred while the employee was performing job-related duties
44
Which of the following best describes the role of a physician in the workers’ compensation system?
Providing medical opinions that guide claims decisions
45
What should a physician consider when establishing causation for a cumulative injury?
The worker's medical history and all relevant exposures
46
How are psychiatric injuries treated differently in workers' compensation claims?
They require a higher standard of proof for causation
47
What is the purpose of taking a complete occupational history?
To understand all jobs the worker has held, including hazards and protective equipment used
48
How is an injury defined under the workers' compensation system?
Any injury or disease arising out of employment
49
Which of the following is considered first aid according to Labor Code § 5401(a)?
One-time treatment for minor injuries like cuts and burns
50
What does "Aggravation" refer to in workers' compensation terms?
A temporary or permanent increase in disability due to work
51
Which of the following best defines "Arising Out of Employment" (AOE)?
An injury directly caused by work activities
52
Which of the following is NOT necessary to establish when determining causation?
The workplace location
53
What is the significance of "Occurring in the Course of Employment" (COE) in workers' compensation?
It involves the circumstances surrounding the accident or exposure
54
What is a "Presumption" in the context of workers' compensation?
A legal assumption that certain conditions are work-related for specific employee groups
55
Under what condition is a psychiatric injury compensable according to Labor Code §3208.3?
If it is a diagnosed mental disorder with employment being the predominant cause
56
What happens if a psychiatric claim is filed after notice of termination or layoff?
It is not compensable unless specific conditions are met
57
Which of the following is an example of an "incidental" activity included in the course of employment?
Traveling on behalf of the employer
58
Which of the following best describes the role of a physician in determining AOE/COE?
To provide medical evidence regarding the relationship between exposure and injury
59
What is the threshold for causation in psychiatric injury claims?
Employment must be the predominant cause of the injury
60
Which of the following could be a compensable consequence of a physical injury?
A psychiatric injury deriving from an underlying physical injury
61
Which of the following is true about workers' compensation for employees who travel on behalf of their employer?
They are covered for the entire travel period unless there is a substantial deviation from the agreed route
62
Who must an employee notify within 30 days if they sustain a work-related injury or illness?
Employer,
63
What form must an employer provide to an employee within one working day of learning about an injury?
Employee’s Claim for Workers’ Compensation Benefits (DWC 1)
64
Which of the following workers is NOT covered under the California workers’ compensation system?
Longshore workers
65
What must an employer do immediately after being notified of a serious injury or death at the workplace?
Report to the Division of Occupational Safety and Health (DOSH)
66
Which party in the workers’ compensation system typically manages the claims and makes key decisions about benefits?
Claims Administrator
67
Who is responsible for ensuring that an employee’s work environment is safe and healthful?
Employer
68
What is the maximum number of chiropractic visits an injured employee can have after January 1, 2004, unless authorized for more?
24 visits
69
Which of the following tasks is typically NOT the responsibility of a claims administrator?
Filing legal claims against the employer
70
What is required for an employee to change their treating physician to a personal chiropractor after a work-related injury?
They must provide the employer with the name and address of the chiropractor before the injury occurs
71
Which document must an employer complete within five days of being notified of an employee’s occupational injury?
Employer’s Report of Occupational Injury or Illness (Form 5020)
72
What happens if an employee does not predesignate a personal physician before sustaining a work-related injury?
The claims administrator has the right to select the treating physician within the first 30 days
73
What is a serious injury as defined by the California workers’ compensation system?
An injury resulting in more than 24 hours of hospitalization for something other than observation
74
Who must provide the employer with written notice before canceling a workers' compensation policy?
Insurance Carrier
75
Under what circumstances can an injured worker’s attorney receive fees directly from the worker’s compensation award?
When the workers' compensation judge or WCAB authorizes it
76
What is the primary role of medical case managers employed by insurers in the workers' compensation system?
To assist in medical and other aspects of the case, including attending physician appointments
77
What must an employer provide to an employee within one working day of learning about an injury?
Employee’s Claim for Workers’ Compensation Benefits (DWC 1)
78
What are Temporary Disability (TD) payments based on?
The employee’s average weekly earnings at the time of the injury
79
How many weeks of Temporary Disability (TD) payments can an injured worker receive if their injury occurred between January 1, 2008, and the present?
104 weeks within five years from the date of injury
80
What type of disability payments are provided to an employee who does not completely recover from an injury?
Permanent Disability (P payments
81
For injuries occurring on or after January 1, 2013, what is the maximum amount of the Supplemental Job Displacement Benefit (SJDB) voucher?
$6,000
82
What happens if an employee with a permanent partial disability does not return to work within 60 days of the termination of Temporary Disability payments?
The employee may qualify for a Supplemental Job Displacement Benefit (SJD voucher
83
Which of the following is covered under Death Benefits in the workers’ compensation system?
Burial expenses up to $10,000 for injuries on or after January 1, 2013
84
What is the purpose of the Return-to-Work Fund?
To make supplemental payments to workers whose permanent disability benefits are disproportionately low in comparison to their earnings loss
85
What is the penalty if an employer discriminates against an employee for filing a workers' compensation claim?
The employer may face legal action and be required to compensate the employee
86
Who is responsible for ensuring that an injured worker receives appropriate benefits in a timely fashion?
The treating physician
87
What is the maximum amount of burial expenses covered under Death Benefits for injuries occurring before January 1, 2013?
$5,000
88
Which benefit compensates employees who are permanently unable to return to their pre-injury job due to a work-related injury?
Permanent Disability (P, Temporary Partial Disability (TP
89
What must an employer do if they fail to provide the necessary medical treatment within one working day after a claim is filed?
Allow the worker to self-procure treatment, with the WCAB retaining jurisdiction over reimbursement
90
How is the amount of Permanent Disability (PD) payments determined?
According to the percentage of disability
91
What type of disability payments can continue for life after the permanent disability amount is exhausted?
A small pension for workers with permanent partial disabilities of 70% or more
92
What percentage of an employee’s estimated wage loss is covered by Temporary Partial Disability (TPD) payments?
66%
93
What is included in Medical Treatment benefits under workers’ compensation?
Interpreter services related to the treatment
94
Which of the following is NOT covered under workers' compensation benefits?
Income from work outside the regular job
95
What happens if an employer offers regular, modified, or alternative work to an injured employee within 60 days of the injury becoming permanent and stationary?
The employee’s disability payments are decreased by 15%
96
What is the penalty for an employer that terminates an injured worker during the period of temporary disability without proving a business necessity?
Legal action and potential compensation to the employee
97
Who is primarily responsible for managing the care of an injured worker in California's workers’ compensation system?
Primary Treating Physician (PTP)
98
Which of the following is a requirement for an MPN in the California workers' compensation system?
Must include a mix of doctors specializing in work-related injuries and general medicine
99
A secondary treating physician is responsible for:
Reporting findings to the Primary Treating Physician (PTP)
100
What is a Medical Provider Network (MPN)?
A network of providers established by the employer or insurer to treat work-related injuries
101
Which of the following is NOT a duty of a Primary Treating Physician (PTP)?
Managing the entire care process independently without reporting to any other entity
102
What is the significance of predesignating a physician in the workers' compensation system?
The employee's predesignated physician can treat the worker even if they are not part of the employer's MPN or HCO
103
What is a Health Care Organization (HCO)?
A managed care organization certified by the DWC to provide health care to employees injured at work
104
In the context of the workers’ compensation system, which of the following is a violation of Labor Code § 139.3?
Referring a patient to a facility where the physician has a financial interest without disclosing it
105
What is required for a physician to use a Physician Assistant (PA) in treating an injured worker?
The physician must evaluate the PA's ability and provide supervision, with a limit of supervising two PAs at a time
106
An employee who fails to predesignate a physician will be treated by:
The HCO or MPN selected by the employer
107
Which of the following statements is TRUE about Medical Provider Networks (MPNs)?
Employees in an MPN must follow the rules and guidelines set by the network
108
Which of the following best describes the role of a secondary treating physician?
They provide additional opinions or treatment but do not manage the case
109
What is the purpose of a Health Care Organization (HCO) in the workers' compensation system?
To manage and deliver medical treatment to employees injured at work
110
Which of the following is a requirement for an injured worker to receive treatment from a predesignated physician?
The physician must have treated the employee in the past and have the employee's medical records
111
Which of the following must be disclosed if a physician has a financial interest in a facility to which they are referring a patient?
The financial interest the physician has in the facility
112
What role does a Primary Treating Physician (PTP) play in determining an injured worker's eligibility for vocational rehabilitation?
They determine medical eligibility for vocational rehabilitation services for injuries before January 1, 2004
113
In which of the following situations is a cross-referral considered legal?
When two doctors, without any financial interest, refer patients to each other based solely on patient care needs
114
Which statement is TRUE regarding the supervision of Physician Assistants (PAs) under California workers' compensation law?
PAs must have all care they provide supervised and approved by a licensed physician
115
What must an employer provide when contracting with a Health Care Organization (HCO)?
A choice of at least one HCO and an open enrollment period for employees
116
If an employee is dissatisfied with the medical treatment provided by the MPN, what is their next step?
The employee must request a second opinion from another doctor within the MPN
117
What is the deadline for submitting the Doctor’s First Report of Occupational Injury or Illness (DFR) after the injured worker's first visit?
5 working days
118
Which report is required to document the ongoing treatment and condition of an injured worker during active treatment?
Primary Treating Physician’s Progress Report (PR-2)
119
What must a treating physician include when requesting treatment through a Request for Authorization (RFA) form?
Documentation substantiating the need for the requested treatment
120
When should a Primary Treating Physician (PTP) submit a Permanent and Stationary Report (PR-3 or PR-4)?
When the employee’s condition becomes stable and unlikely to improve
121
If a physician fails to submit a Doctor’s First Report of Occupational Injury or Illness (DFR), what consequences might arise?
The injured worker’s benefits may be delayed, and the physician may face civil penalties
122
What information is NOT required in the Doctor’s First Report of Occupational Injury or Illness (DFR)?
The estimated cost of treatment
123
What triggers the need for a Primary Treating Physician’s Progress Report (PR-2)?
All of the above
124
Which form must be completed by a treating physician to request diagnostic tests or other medical services for an injured worker?
Request for Authorization (RFA)
125
Under what circumstances is a specialist required to complete a Doctor’s First Report of Occupational Injury or Illness (DFR)?
Only if the treating physician has not already submitted a DFR
126
What is the purpose of the Permanent and Stationary Report (PR-3 or PR-4)?
To document the injured worker’s condition once it becomes stable and unlikely to improve
127
How often must a Primary Treating Physician (PTP) submit progress reports during periods of active treatment?
At least every 45 days
128
Which of the following is required in the Permanent and Stationary Report (PR-3 or PR-4)?
A history of the injury and the patient’s complaints
129
If a treating physician makes a verbal request for treatment, what must they do next?
Confirm the request in writing using the Request for Authorization (RFA) form
130
Which form is used to assess the existence and extent of permanent impairment after an employee’s condition becomes permanent and stationary?
Permanent and Stationary Report (PR-3 or PR-4)
131
What should a PTP do if the injured worker's condition requires new durable medical equipment or orthotic devices?
Report the need in a Primary Treating Physician’s Progress Report (PR-2)
132
What is the primary purpose of Evidence-Based Medicine (EBM)?
To integrate the best available research evidence with clinical expertise and patient values
133
Which schedule must be followed when evaluating and treating ill and injured workers in California?
Medical Treatment Utilization Schedule (MTUS)
134
Which concept is central to the treatment of work-related injuries according to the MTUS?
Functional improvement
135
The MTUS is presumed correct on the issue of medical treatment. How can this presumption be successfully challenged?
By providing high-quality scientific medical evidence
136
What is the role of the Medical Evidence Evaluation Advisory Committee (MEEAC)?
To provide recommendations on updates to the MTUS
137
Which of the following is NOT a clinical topic covered by the MTUS?
Cardiac conditions
138
What does the MTUS provide for medical providers?
Treatment frequency, intensity, and duration recommendations
139
What is the most recent role clarified in the MTUS revisions?
The role of the MTUS as the standard of medical care for work-related illness or injury
140
Which model is highlighted in the MTUS for understanding chronic pain?
Biopsychosocial
141
What is functional improvement as defined by the MTUS?
Clinically significant improvement in activities of daily living or reduction in work restrictions
142
The MTUS is periodically updated to include new evidence. Which guideline chapters are specifically mentioned as being incorporated?
ACOEM and ODG
143
According to the MTUS, which factor is a better predictor of chronic pain than clinical findings?
Psychosocial factors
144
What is the primary goal of Utilization Review (UR) in workers' compensation?
To avoid unnecessary testing and treatments that may be harmful and costly
145
Who is required by law to have a Utilization Review (UR) program in place?
All employers or their workers’ compensation claims administrators
146
What must be filed with the DWC Administrative Director as part of the UR program?
UR plans
147
Who can approve a treatment request in the Utilization Review (UR) process?
Any member of a UR organization
148
In what situation must a treatment request be reviewed by a physician during the UR process?
When the request is not approved at the adjuster or claims representative level
149
What can a chiropractic physician reviewer evaluate during the UR process?
Tests or treatments within the scope of chiropractic practice
150
How soon must a decision be communicated to the treating doctor after a concurrent or prospective request?
Within 5 working days
151
What happens if additional information needed for a UR decision is not received within 14 days?
The request is denied
152
Which of the following describes "Prospective Review" in the UR process?
Review conducted prior to the delivery of medical services
153
What is the maximum timeframe for making a decision related to an expedited review in the UR process?
72 hours
154
What is the main purpose of Independent Medical Review (IMR) in California's workers' compensation system?
To resolve disputes about the medical treatment of injured employees
155
Who can request an Independent Medical Review (IMR)?
The injured employee or their designee
156
What must be submitted with the IMR application within 30 days to request a review?
Signed IMR application and a copy of the UR denial or modification
157
What could cause an IMR to be terminated?
The treatments in dispute are authorized
158
Who must make decisions on the medical necessity of treatment requests during IMR?
Licensed physicians knowledgeable in the treatment of the injured worker’s condition
159
What is the highest-ranking standard to be used when making medical necessity decisions during IMR?
The Medical Treatment Utilization Schedule (MTUS)
160
Within how many days must the final IMR decision be provided in writing to all parties?
14 days
161
On what grounds can an IMR decision be appealed?
The final determination was procured by fraud
162
What must be done if a UR decision also involves a dispute of liability?
The request for IMR is extended to 30 days after the liability dispute is resolved
163
What is required for an expedited IMR request?
The treating physician’s certification that the employee faces an imminent and serious threat to their health
164
What role do physicians play in disability evaluations?
Determining the impairment rating and eligibility for disability payments
165
Which of the following forms might a Primary Treating Physician (PTP) use to report a permanent disability?
DWC PR-3 or PR-4
166
What is the purpose of the Disability Evaluation Unit (DEU)?
To assign permanent disability ratings based on physicians' evaluations
167
Which of the following is NOT a required component of a final disability evaluation report?
Workers' compensation insurance policy number
168
What does the term "Permanent and Stationary" (P&S) indicate in a disability evaluation?
The worker’s condition has stabilized and is unlikely to improve further
169
What is the Almaraz-Guzman Standard used for?
Rebutting a permanent disability rating when the AMA Guides are deemed inadequate
170
According to the AMA Guides, what is the definition of "impairment"?
A loss, loss of use, or derangement of any body part, organ system, or organ function
171
How is "disability" defined according to the AMA Guides?
An alteration of an individual’s capacity to meet personal, social, or occupational demands due to impairment
172
What is the primary goal of the AMA Guides?
) To provide a standardized, objective approach to evaluating medical impairments
173
Which method is commonly used in the AMA Guides to assess spinal impairment?
Diagnosis-Related Estimate (DRE)
174
What is the purpose of the Combined Values Chart in the AMA Guides?
To combine multiple impairment ratings into a single whole person impairment (WPI)
175
In what scenario might a physician use the Range of Motion (ROM) method for assessing spinal impairment?
When the condition cannot be easily categorized, such as multilevel fusions
176
What is the maximum additional percentage a physician can add to a Whole Person Impairment (WPI) rating for pain, according to the AMA Guides?
3%,
177
What is a key difference in how the AMA Guides and the previous system in California evaluate permanent disability?
The AMA Guides focus on impairment related to activities of daily living, rather than work capacity
178
What must a physician provide when using an alternative rating method under the Almaraz-Guzman Standard?
Substantial medical evidence and a clear rationale for the chosen method
179
What is NOT a purpose of a disability evaluation in the workers’ compensation system?
To decide the worker’s guilt or innocence in causing the injury
180
What approach should a physician take when evaluating a worker using an assistive device, according to the AMA Guides?
Evaluate with and without the device when possible
181
What is the primary focus of a physician’s responsibility when conducting a permanent disability evaluation using the AMA Guides?
Providing an impairment rating
182
In California, what does the AMA Guides’ approach to pain in disability evaluations involve?
A conservative addition of up to 3% to the WPI rating when pain is greater than normally associated with the injury,
183
What is required of a physician when documenting the process used to derive an AMA Guides impairment rating?
Thorough documentation of the rationale and references to the relevant AMA Guides sections
184
What is the primary role of a Qualified Medical Evaluator (QME)?
To conduct medical-legal evaluations in workers’ compensation cases
185
Who appoints Qualified Medical Evaluators (QMEs) in California?
The Division of Workers' Compensation Medical Unit
186
What is required for a physician to be eligible to become a QME?
They must devote at least one-third of their practice to providing direct medical treatment
187
When can an Agreed Medical Evaluator (AME) be used?
Only if both the employee and employer agree on a physician
188
What happens if the represented parties cannot agree on an AME?
Either party may request a QME panel to resolve the dispute
189
How long is the appointment term for a Qualified Medical Evaluator (QME)?
) Two years
190
Who can request a medical-legal evaluation if there is a disagreement with the treating physician's evaluation?
Either the employer or the employee
191
What is the purpose of a medical-legal evaluation in a workers’ compensation case?
To determine medical issues relevant to the workers’ compensation claim
192
What must the QME do if there is no referral letter accompanying the request for an evaluation?
Determine the relevant issues based on available records and discussion with the injured worker
193
What is required if an unrepresented employee fails to request a QME panel within 10 days after the employer’s request?
the employer may then request a QME panel
194
How many QMEs are listed in a QME panel generated by the DWC Medical Unit?
Three
195
What must a QME report include to be considered complete?
The physician’s findings and the reasons for all opinions
196
How soon must the employer pay reasonable charges for a medical-legal report under the fee schedule?
Within 60 days
197
When can a Permanent and Stationary (P&S) report be contested in a workers’ compensation case?
When either party objects to the findings
198
What must be addressed in all medical-legal reports regarding permanent disability?
The issue of apportionment
199
What is the primary purpose of a medical-legal report in a workers' compensation case?
To assist nonmedical personnel in making decisions affecting the worker's life
200
Which of the following is a required element in a medical-legal report?
History of present injury or illness
201
Why is it important for a medical-legal report to be clear, concise, and internally consistent?
To enable nonmedical personnel to make informed decisions
202
What must be included in the "Identifying Information" section of a medical-legal report?
Date of the report, name of the applicant, and date of injury
203
How much face-to-face time is required for a psychiatric evaluation in a medical-legal report?
60 minutes
204
In the context of workers' compensation, what does "apportionment of disability" refer to?
The degree to which permanent disability is due to pre-existing conditions
205
Which form must be reviewed and possibly commented on by the physician for unrepresented workers in a QME evaluation?
DEU Form 100
206
What is the significance of using appropriate terminology in a medical-legal report?
To align with the logic and definitions of workers' compensation law
207
What should be included in the "Present Complaints" section of a medical-legal report?
Detailed description of the patient's current complaints and related activities
208
What should a physician do if there are conflicting accounts of how the injury occurred?
Provide an opinion conditionally based on each possible scenario
209
Why is it important to summarize important medical events or conditions in the report?
) To provide context for the injury and its impact on the worker's disability
210
What is the role of a physician in determining the cause of injury in a medical-legal report?
To explain how the injury is related to the worker's employment
211
What is the primary purpose of Labor Code § 4600 in relation to medical treatment for injured workers?
To guarantee treatment that cures or relieves the effects of the injury
212
Which type of medical treatment dispute must be resolved through Independent Medical Review (IMR)?
Current medical treatment disputes
213
Which of the following must a medical-legal report NOT include when discussing future medical treatment?
Exact dollar amounts for future treatment
214
Why is it important for a physician to provide detailed reasoning for each opinion in a medical-legal report?
To prevent the report from being deemed worthless in the workers' compensation system
215
What role does the WCAB play in the evaluation of future medical treatment needs?
They assess the reports from the treating physician and possibly a QME at the time care is requested
216
What must be disclosed in the medical-legal report regarding other individuals involved in the evaluation process?
Their names, qualifications, and roles in the evaluation
217
When is a physician required to provide future medical treatment in a workers' compensation case?
When it is needed to relieve or cure the effects of the injury
218
What happens if a medical-legal report is submitted without adequate reasoning behind the medical opinions?
The report is considered worthless in the workers' compensation system
219
In what situation would the WCAB not be bound by a physician’s estimate of future medical needs?
When reviewing a P&S report
220
Which of the following must be included in every medical-legal report under penalty of perjury?
A mandatory declaration stating that the report is true and correct
221
Why should a physician avoid providing finite numbers and dollar amounts for future medical treatment in their reports?
Because the future needs cannot be precisely predicted
222
What must a physician disclose if they have a significant beneficial interest in a facility used in the evaluation?
Their proprietary interest or co-ownership of the facility
223
What is the purpose of the Official Medical Fee Schedule (OMFS)?
To establish the maximum allowable fee for services
224
Which fee schedule is the Physician Fee Schedule based on?
Resource-Based Relative Value Scale (RBRVS)
225
What is a key element of the RBRVS fee schedule?
Relative value units (RVUs)
226
How often is the Physician Fee Schedule updated?
Annually
227
What is required for a medical provider to request an Independent Bill Review (IBR)?
Completion of a second bill review
228
Which billing form is used by health-care providers for paper submissions?
Form CMS-1500
229
What is the time limit for submitting a Request for Second Bill Review after receiving an Explanation of Review (EOR)?
90 days
230
What factor is used to adjust payments for geographic differences in costs under the RBRVS system?
Geographic Adjustment Factor (GAF)
231
What does the Multiple Procedure Payment Reduction (MPPR) apply to?
Physical medicine and surgery
232
What is the primary benefit of electronic billing over paper billing?
Faster payment processing
233
Which entity currently serves as the Independent Bill Review Organization (IBRO) for California workers' compensation?
Maximus Federal Services
234
What is the basis for calculating maximum fees for anesthesia services under the Physician Fee Schedule?
A separate conversion factor for anesthesia, A single national conversion factor
235
What must be included with a Request for Second Bill Review?
Additional documentation supporting the billing
236
How are missed appointments communicated under California Specific Codes?
WC012
237
What is required for a provider to appeal an IBR determination?
Filing with the Workers’ Compensation Appeals Board (WCA
238
Which regulation outlines the formulas for calculating fees for services other than anesthesia?
8 CCR §9789.12.2
239
What is the deadline for claims administrators to pay an electronic bill after receiving it?
15 days
240
Which billing format is consistent with HIPAA standards in California workers’ compensation?
Electronic Billing
241
What happens if an IBR application is withdrawn after assignment to an IBRO?
The fee will not be reimbursed
242
What is one of the ground rules that differ from Medicare under the Physician Fee Schedule?
Multiple Procedure Payment Reduction (MPPR) for Radiology Diagnostic Imaging
243
What is the main responsibility of the DWC Audit and Enforcement Unit?
To conduct audits of claims administrators to ensure compliance with workers' compensation laws
244
How often are claims administrators normally subject to routine investigations?
Once every five years
245
What triggers a targeted investigation of a claims administrator by the DWC?
A credible complaint or failure of a routine investigation
246
What happens if a URO fails a routine investigation?
The DWC may return for a targeted investigation
247
What must MPNs and HCOs demonstrate to maintain approval or certification?
Compliance with regulations regarding employee notifications and provider lists
248
Who can file complaints about the behavior of Qualified Medical Evaluators?
Injured workers, attorneys, and claims administrators
249
What disciplinary actions can the DWC take against a QME for violations?
Formal reprimand, suspension, or revocation of QME status
250
Under what circumstances can a QME be suspended without a hearing?
If their medical license has been revoked
251
What is the role of the DWC Medical Unit in overseeing UROs?
Investigating compliance with UR regulations and assessing penalties
252
Which of the following is NOT a potential ground for QME disciplinary action?
Failure to pay administrative fees on time
253
What is the main purpose of the DWC’s investigation of UROs?
To ensure that responses to physicians’ requests for treatment are timely and comply with regulations
254
Who is responsible for overseeing employers' compliance with regulations related to workers' compensation insurance?
The Division of Labor Standards and Enforcement and the Department of Insurance
255
What is the primary responsibility of a treating physician in the workers' compensation system?
To treat the patient fairly and ethically
256
What role does the Labor Code play in regulating medical-legal evaluations?
It clarifies and codifies the role of evaluating physicians
257
Why might the appearance of impropriety develop in workers' compensation cases?
Physicians may have business relationships with parties involved
258
What is a QME required to do when conducting a medical-legal evaluation?
Personally examine the applicant and take a thorough history
259
According to the chapter, what should a physician do if a worker refuses to provide information or sign a release?
Litigate the issue before the WCAB
260
Which of the following is true about the use of interpreters during medical-legal evaluations?
The employer or insurance company must provide a certified interpreter
261
What is one key difference between a treating physician's report and a QME's report?
A treating physician’s report is not generated from a disputed issue
262
What is a physician advised to do if an injured worker appears nervous or evasive during an exam?
Understand the worker's possible apprehension and try to be objective
263
What should a QME mention in their report if a certified interpreter was used?
The interpreter’s name
264
In what scenario might a QME exam be recorded?
If both parties agree and the QME consents to the recording
265
What is the maximum time an injured worker can be kept waiting before they can terminate the QME exam?
1 hour
266
Under which condition can a QME terminate an exam?
If the injured worker is intoxicated
267
If an injured worker terminates an exam due to discriminatory conduct, what is the next step?
The worker may request a new QME
268
What happens if a judge determines there was no good cause for terminating the QME exam?
The cost of the evaluation is deducted from the worker’s award
269
Can a QME become a treating physician after conducting an evaluation?
Yes, but only if the injured worker requests it
270
Under what condition may a QME provide treatment to an injured worker after the evaluation?
If the injured worker formally requests the QME as their treating physician
271
What must a QME do if they disagree with the treating physician's assessment that the worker’s condition is permanent and stationary?
Discuss the basis for their disagreement in the report
272
In what scenario is ex parte communication allowed for a QME?
When requesting medical records in writing with a copy served on the injured worker
273
What is considered ex parte communication by a QME?
Contacting the defense attorney for additional records without informing the injured worker
274
How should a QME handle receiving nonmedical records or films?
They should only view them if neither party objects
275
Who has the initial discretion to terminate a QME exam due to violations of ethical guidelines?
The injured worker
276
What must a QME do after rescheduling an appointment due to a delay?
Inform the claims administrator of the new appointment time within five days
277
When can an injured worker terminate a QME exam due to improper conduct?
If the evaluator makes improper sexual advances
278
What must happen if a new QME examination is necessary after a QME becomes the treating physician?
A new QME panel must be requested
279
What is a QME prohibited from doing regarding nonmedical records if a party objects?
Viewing the nonmedical records or films
280
What is required on bills submitted by treating physicians for injured workers?
A declaration that they were not in violation of Labor Code § 139.3 (self-referral)
281
Which types of self-referrals are specifically prohibited?
Referrals to facilities where the physician or their family has a financial interest
282
What must a physician do if they refer a patient to a facility in which they have a financial interest?
Disclose their financial interest to the patient
283
In what case is a physician not required to obtain preauthorization for physical therapy referrals?
When the physician’s regular practice is outside a metropolitan area with no alternatives available within 25 miles
284
What is the consequence of violating referral prohibitions under Labor Code § 139.31(e)?
A misdemeanor charge
285
Under what circumstances may medical records related to HIV status be disclosed without patient authorization?
When the patient claims HIV infection through an employment-related exposure
286
What should a physician do if they receive a subpoena for medical records related to a work injury?
Respond to the subpoena, but consult with the patient or their attorney first
287
Which of the following actions is considered a felony under Labor Code § 3219?
Offering compensation to a claims adjuster for referrals
288
What is required for a valid subpoena related to a workers’ compensation claim?
The injured worker must receive a copy of the subpoena
289
What should treating physicians explain to patients about confidentiality in workers’ compensation cases?
How their medical information will be shared with employers and insurers
290
What are QMEs and AMEs required to ensure in their evaluations?
Maximum compensation for the injured worker
291
Which of the following is considered appropriate advertising for QMEs?
Listing the physician’s area of practice and languages spoken
292
What is the penalty for making false or fraudulent workers’ compensation claims?
Up to five years in prison or a fine of up to $50,000
293
What must evaluators avoid when providing medical opinions?
Accepting compensation contingent on writing a biased report
294
Which of the following actions is NOT a violation of the self-referral laws?
Referring a patient for a nonprohibited service with proper disclosure
295
What should be used to bill for treatment and most reports under California workers’ compensation laws?
Official Medical Fee Schedule
296
When should the QME Appointment Notification Form be completed and sent to the involved parties?
Within 10 working days of scheduling
297
If an injured worker makes a QME appointment, what is the maximum number of days allowed before the appointment to avoid difficulties in obtaining records?
25 days
298
What form must be submitted with the QME evaluation for disability rating by the DEU?
DEU Forms 100 and 101
299
What must be included in the total package sent to the DEU office for rating a QME evaluation?
QME evaluation, Findings Summary Form, DEU Forms 100 and 101, and Proof of Service
300
What is the time frame for serving a QME report for injuries occurring after January 1, 1994?
30 days
301
How long does a QME have to request an extension for a report if test results are delayed?
25 days
302
Which form must be used to request a time extension for submitting a QME report?
QME Form 112
303
What should be done if the medical records are not received by the QME appointment date?
Contact the employer/insurer to request records
304
Who is responsible for serving the QME report to the DWC or WCAB?
The parties involved
305
What is the fee for requesting Independent Bill Review (IBR)?
$250.00
306
What happens if a QME report is not completed within the extended time frame?
The original evaluation may be deemed inadmissible
307
Which form is used to notify the parties about the QME appointment?
QME Form 110
308
Who must receive a copy of the QME report in a panel QME case for an unrepresented injured worker?
The injured worker, claims administrator, and local DEU office
309
What is required to consolidate separate IBR requests?
Common issues of law and fact or similar services
310
What form should be used if an Independent Bill Review request is withdrawn?
No specific form required
311
What is the maximum amount of a dispute that can be consolidated in IBR?
$4,000,
312
How should the QME report be served to all parties?
With proof of service attached
313
If a provider wishes to appeal an IBR determination, how long do they have to file a petition with the WCAB?
20 days
314
What should be done if the injured worker does not have the required DEU Forms 100 and 101?
Have the worker complete Form 100 at the appointment and ensure Form 101 is received
315
What does "AA or A/A" stand for in workers' compensation terminology?
Applicant’s attorney
316
What is an "Accepted claim" in workers' compensation?
A claim in which the insurance company agrees that an employee’s injury or illness is covered by workers’ compensation
317
What does "ACOEM" stand for?
American College of Occupational and Environmental Medicine
318
Who is the "AD" in the context of workers' compensation?
Administrative Director of the Division of Workers’ Compensation
319
Which of the following best defines "ADA"?
Americans with Disabilities
320
What does "ADL" stand for in the workers' compensation field?
Activities of Daily Living
321
Which of the following is the role of an "Administrative Law Judge (WCALJ, ALJ, Judge)"?
To preside over disputes in workers' compensation cases
322
What is an "Aggravation" in the context of workers' compensation?
A worsening of a non-industrial pre-existing condition due to work exposure
323
Who is an "Agreed medical evaluator (AME)"?
The doctor agreed upon by the worker’s attorney and the insurance company
324
What is an "Agreed QME"?
An evaluator chosen when an objection is made to an issued panel and both parties agree on the QME
325
What is meant by "Alternative work" in the workers' compensation system?
A new job offered by the former employer that meets the employee’s work restrictions
326
What is the "American Medical Association (AMA)" known for in workers' compensation?
Publishing the "Guides to the Evaluation of Permanent Impairment"
327
What does "AOE" stand for in the context of a workers' compensation claim?
Arising Out of Employment
328
What is the role of the "Appeals board" in workers' compensation?
To review and reconsider decisions of workers’ compensation administrative law judges
329
Who is typically the "Applicant" in a workers' compensation case?
The injured employee who files a claim
330
Who does an "Applicants’ attorney" represent in a workers' compensation case?
The injured employee
331
What is an "Application for adjudication of claim"?
A form filed to open a case at the Workers’ Compensation Appeals Board office
332
What does "Apportionment" determine in a workers' compensation case?
How much of an employee’s permanent disability is due to the work injury versus other causes
333
What does "AOE/COE" mean in workers' compensation?
Arising Out of and Occurring in the Course of Employment
334
What is the role of the "Audit Unit" in the Division of Workers' Compensation?
Ensuring that insurance companies, self-insured employers, and third-party administrators adhere to the regulations and laws governing workers' compensation claims.
335
What does an "Award" refer to in the workers' compensation system?
A decision by the Workers’ Compensation Appeals Board regarding benefits
336
What does "AWW or AWE" stand for in workers' compensation?
Average Weekly Wage or Earnings
337
Fair Employment and Housing Act (FEHA) prohibits discrimination against:
People with disabilities
338
The Family and Medical Leave Act (FMLA) provides up to how many weeks of unpaid, job-protected leave per year?
12 weeks
339
Filing refers to:
Sending or delivering a document to an employer or a government agency
340
A Final Order is:
An order, decision, or award made by a workers' compensation judge that has not been appealed
341
Findings & Award (F&A) is:
A written decision by a workers’ compensation administrative law judge about an employee’s case
342
First Aid in the workers’ compensation system refers to:
Treatment provided by a physician or licensed medical provider on a one-time basis for a minor condition
343
A Flare-up of a Pre-Existing Condition is also known as:
Recurrence of a Pre-Existing Condition
344
Fraud in the workers’ compensation system involves:
Knowingly making a false statement to obtain or deny workers’ compensation benefits
345
Functional Capacity Evaluation (FCE) is:
A formal assessment of an individual’s physical capabilities
346
Future Earning Capacity (FEC) refers to:
A multiplier that increases the disability rating based on wage loss caused by an injury
347
Future Medical Treatment is:
Treatment anticipated at some time in the future to cure or relieve the effects of an injury
348
Ghostwriting in medical-legal reports is:
When a medical report is prepared by someone other than the physician who performed the evaluation
349
A Health Care Organization (HCO) is:
An organization certified by the DIR to provide managed medical care within the workers’ compensation system
350
Hearings in the workers’ compensation system are:
Legal proceedings where a judge discusses issues in a case or receives information
351
Impairment is defined as:
The reduction or loss of function of an organ or body part
352
An Impairment Rating is:
A percentage estimate of how much normal use of the worker’s injured body parts has been lost
353
In Pro Per refers to:
An injured worker not represented by an attorney and acting as their own attorney
354
An Independent Contractor is someone who:
Has control over how their work is done and is not considered an employee
355
An Independent Medical Examiner (IME) is:
The same as a Qualified Medical Examiner (QME)
356
The Industrial Medical Council (IMC):
No longer exists and is now called the Medical Unit
357
Independent Medical Review (IMR) allows an employee to:
Seek a second and third opinion if they dispute their physician’s recommended tests or treatments
358
An Information & Assistance (I&A) Officer:
Answers questions and assists injured workers within the DWC
359
The Information & Assistance Unit (I&A):
Provides information and informally resolves disputes in workers’ compensation claims
360
An Injured Worker is:
Another term for an injured employee or applicant
361
Injury in the workers' compensation system refers to:
A new injury, illness, or a pre-existing condition made worse by work-related exposure
362
The Injury and Illness Prevention Program (IIPP):
Is a required health and safety program that employers must implement
363
A Judge (WCALJ, WCJ) in the workers' compensation system is:
Also known as a Workers’ Compensation Administrative Law Judge
364
A Lien in the workers' compensation context is:
A right or claim for payment against a workers’ compensation case
365
Maximum Medical Improvement (MMI) is:
When the injured worker’s condition is well stabilized and unlikely to change substantially
366
A Mediation Conference is:
A voluntary conference held to resolve a dispute if an employee is not represented by an attorney
367
Medical Care in the workers’ compensation system is also known as:
Medical Treatment
368
A Medical Determination is:
A decision made by the primary treating physician regarding the employee’s eligibility for compensation
369
A Medical-Legal Report is:
A report written by a doctor to clarify disputed medical issues
370
A Medical Provider Network (MPN) is:
An entity or group of health-care providers set up to treat workers injured on the job
371
Medical Treatment is defined as:
Treatment reasonably required to cure or relieve the effects of a work-related injury or illness
372
The Medical Treatment Utilization Schedule (MTUS):
Contains guidelines on effective treatments for work-related injuries
373
The Medical Unit within the DWC:
Oversees MPNs, IMR physicians, HCOs, QMEs, and other medical-related entities
374
Modified Work is:
An injured worker’s old job with some changes to accommodate their abilities
375
Objective factors refer to:
Measurements, direct observations, and test results contributing to permanent disability
376
Occupational disease is:
A disease caused in whole or in part by work
377
Off calendar (OTOC) means:
A WCAB case in which there is no pending action
378
Offer of modified or alternative work (DWC form #AD 10133.53) is:
A form sent to an injured worker offering modified or alternative work instead of a supplemental job displacement benefit
379
Offer of modified or alternative work form (RU-94) applies to:
Injured workers who were injured before 2004 and may not return to their old job
380
Official Medical Fee Schedule (OMFS) refers to:
A fee schedule used for payment of medical services required to treat work-related injuries
381
Order Approving Compromise and Release (OACR) is:
An order issued by a workers' compensation judge that finalizes a settlement agreement
382
OSHA stands for:
Occupational Health and Safety Act, Office of Safety and Health Appeals
383
P&S report is:
A medical report written by a treating physician when the employee’s condition has stabilized
384
Panel-qualified medical evaluator (QME/PQME) refers to:
A list of three independent QMEs from which the injured worker selects one for evaluation
385
Party in a workers’ compensation case usually includes:
The insurance company, employer, attorneys, and any other person with an interest in the claim
386
Penalty in a workers’ compensation case refers to:
An amount paid by the employer or insurance company for not handling a claim correctly
387
Permanent and stationary status (P&S) means:
The point at which the employee has reached maximum medical improvement
388
Permanent disability (PD) is defined as:
Any lasting disability that results in a reduced earning capacity after maximum medical improvement is reached
389
Permanent disability advance (PDA) is:
A voluntary lump sum payment of permanent disability the injured worker is due in the future
390
Permanent disability rating (PDR) refers to:
A percentage that estimates how much a job injury permanently limits the kinds of work an individual can do
391
Permanent disability rating schedule (PDRS) is:
A DWC publication containing detailed information used to rate permanent disabilities
392
Permanent disability payments are:
Mandatory biweekly payments based on the undisputed portion of permanent disability received before or after an award is issued
393
Permanent partial disability (PPD) is:
A disability that interferes with the injured employee’s future earning capacity
394
Permanent partial disability award is:
A final award of permanent partial disability made by a workers’ compensation judge or the WCAB
395
Permanent partial disability (PPD) benefits are:
Payments the employee receives when their work injury partially limits the kinds of work they can do or their ability to earn a living
396
Permanent total disability (PTD) refers to:
Disability considered to render an injured employee totally unable to have future earning capacity
397
Permanent total disability (PTD) benefits are:
Payments the injured worker receives when they are considered permanently unable to earn a living
398
Personal physician is:
A doctor licensed in California with an MD or DO degree who has treated an employee in the past and has their medical records
399
Petition for reconsideration (Recon) is:
A legal process to appeal a decision issued by a workers’ compensation judge
400
Physician in workers’ compensation refers to:
A medical doctor, osteopath, psychologist, acupuncturist, optometrist, dentist, podiatrist, or chiropractor licensed in California
401
Predesignated physician is:
A physician who can treat an employee’s work injury if the employee advised the employer in writing prior to the injury and certain conditions are met
402
Predesignation is:
The process employees use to tell an employer that they want their personal physician to treat them for a work injury
403
Preponderance of evidence means:
Evidence that, when weighed against opposing evidence, is more convincing and a higher probability of truth
404
Presumptive work-related injuries are:
Injuries or conditions defined by the legislature as presumptively work-related for workers in specific categories of employment, like peace officers or firefighters
405
Primary treating physician (PTP) is:
The doctor with overall responsibility for treatment of an employee’s work injury or illness
406
Proof of service is:
A form used to show that documents have been sent to specific parties
407
Qualified injured worker (QIW) refers to:
A worker entitled to vocational rehabilitation benefits
408
Qualified medical evaluator (QME) is:
An independent physician certified by the DWC Medical Unit to perform medical evaluations
409
Qualified rehabilitation representative (QRR) is:
A person trained and able to evaluate, counsel, and place disabled workers in new jobs
410
Reasonable medical probability means:
The standard a physician is expected to follow when rendering a medical opinion, meaning there is at least a 51% likelihood of certainty attached to the opinion
411
Recurrence of a pre-existing condition refers to:
A previous industrial injury or illness that becomes symptomatic but not due to the effects of current employment
412
Regular work means:
An employee’s old job, paying the same wages and benefits as paid at the time of an injury and located within a reasonable commuting distance of where the employee lived at the time of the injury
413
Rehabilitation consultant is:
A DWC employee who oversees vocational rehabilitation procedures and helps resolve disputes
414
Released from care means:
A determination by the PTP that the employee’s condition has reached a permanent and stationary status with no need for continuing or future medical treatment
415
Represented employee is:
An injured employee who is represented by an attorney
416
Restrictions in workers' compensation refer to:
A doctor’s description of the work the employee can and cannot do, Limitations on the benefits an employee can receive
417
Salary continuation refers to:
A benefit that allows an injured worker to continue to receive their full salary in lieu of temporary disability benefits
418
Self-administered claim is:
A workers' compensation claim that is handled directly by the employer or a third-party administrator, not an insurance company
419
Settlement in a workers’ compensation case refers to:
An agreement between the injured worker and the employer or insurance company that resolves the case
420
Social Security disability benefits (SSDI) are:
Payments made by the Social Security Administration to cover total disability lasting at least a year or expected to result in death
421
Specific injury is defined as:
An injury caused by one event at work, such as a fall
422
State average weekly wage (SAWW) is:
The average weekly wage paid in the state of California to employees covered by unemployment insurance
423
Statute of limitations refers to:
A law that puts time limits on how long a person has to file a legal claim
424
Stipulated Findings and Award is:
An agreement between the injured worker and claims administrator that resolves the case
425
Stipulation with Request for Award refers to:
An agreement on specific issues submitted to a judge for a decision on the remaining issues or approval
426
Subjective factors in workers' compensation are:
The amount of pain and other symptoms described by the injured worker, contributing to permanent disability
427
Subsequent Injuries Benefits Trust Fund (SIBTF) is:
A state fund that pays additional benefits to workers who already had a disability or impairment at the time of injury
428
Supplemental job displacement benefit (SJDB) is:
A $6,000 voucher for injured workers injured after 1/1/04 who are eligible for retraining or skill enhancement, offered if the employer does not offer regular, modified, or alternative work
429
Temporary partial disability (TPD) refers to:
Payments made when the employee cannot do their usual job while recovering but can work with reduced hours or wages
430
Temporary partial disability (TPD) benefits are:
Payments the employee receives if they can do some work while recovering, but earn less than before the injury
431
Temporary total disability (TTD) is:
Payments made if the employee cannot work at all while recovering from an injury
432
Temporary total disability (TTD) benefits are:
Payments the employee receives if they cannot work at all while recovering
433
Treating doctor is:
The doctor with overall responsibility for treating the injured worker’s condition
434
Uninsured Employers Fund (UEF) is:
A fund run by the DWC that pays benefits to injured workers whose employers are illegally uninsured
435
Utilization review (UR) refers to:
The process used by insurance companies to decide whether to authorize and pay for treatment recommended by the treating physician or another doctor
436
Vocational rehabilitation (VR) is:
A benefit for workers injured before 1/1/04 that helps pay for retraining or skill enhancement if the injured worker is unable to return to their job
437
Workers' Compensation Appeals Board (WCAB) is:
The court that handles workers' compensation appeals
438
Workers' Compensation Insurance Rating Bureau (WCIRB) is:
An organization that provides information about workers’ compensation rates and statistics
439
What are work restrictions?
A doctor's description of the work an employee can and cannot do
440
What does the term 'Q.M.E' stand for?
Qualified Medical Evaluator
441
How is the term 'A.M.E' defined?
Agreed Medical Evaluator.
442
Under Title 8, Section 35 of the California Code of Regulations, who within the DWC is tasked with appointing physicians as Qualified Medical Evaluators (QMEs)?
The Administrative Director of the D.W.C.
443
What is the duration of a QME’s term?
2 years.
444
What types of practitioners are encompassed by the term 'physician' according to the DWC?
California licensed: MDs, DOs, psychologists, acupuncturists, optometrists, dentists, podiatrists, and chiropractors.
445
Who is eligible to become a QME?
Only Physicians, as defined by the Labor Code, can be a QME. Per the DWC, Physicians are: M.D.’s, D.O.’s,Psychologists, Acupuncturists, Dentists, Podiatrists, Chiropractors, and Optometrist.
446
What are the four eligibility criteria required to become a QME?
Pass the QME competency examination.Complete a 12-hour writing course.Submit a form regarding Disclosure of Specified Financial Interests.Devote at least one-third of total practice time to providing direct medicaltreatment.
447
True or false: QMEs are obligated to disclose all financial interests of 5% or more in any medical operation providing treatment, evaluations, goods, or services used within California’s Workers' Compensation system.
True.
448
What two alternative qualifications must a physician meet to become a QME if they lack the required amount of direct medical treatment experience?
The physician must have served as an AME (Agreed Medical Evaluator) on eight or more occasions in the 12 months prior to the end of their 2-year term.The physician must demonstrate that they are disabled, retired, or teaching.
449
What is the minimum amount of time a QME must dedicate to direct medical treatment, and what are the two exceptions to this rule?
The QME served as an AME 8 or more times in the past year.The QME is disabled, retired, or is a teaching physician.
450
What are the three distinct ways a physician can list a specialty?
Board certification in that specialty.Completed postgraduate specialty training (certificate of completion).Grandfathered in: held an appointment as a QME in that specialty on June 30, 2000.
451
After satisfying the initial three qualifications to become a QME, what additional four criteria must be met after two years for reappointment?
Compliance with all applicable regulations and evaluation guidelines.Completion of at least 12 hours of continuing education.No more than 5 rejected reports by a Workers’ Compensation Judge.No termination, suspension, or probation by any licensing board..
452
What are the two ways a QME can face termination or suspension?
The QME’s license to practice has been suspended, revoked, or terminated bytheir licensing board.The QME failed to pay the required fee for reappointment.
453
How many locations can a QME register for QME work?
10
454
Can a QME provide medical treatment to an injured worker?
Ordinarily, no. There are two exceptions: 1. The injured worker requests it. (For instance, a QME sees an injured worker. The injured worker then freely chooses the QME as their primary treating provider (PTP). The QME must then excuse themselves from future QME evaluations with that injured worker).2. Under emergency situations.
455
Can a QME invite an injured worker to become a patient in their private practice while conducting an evaluation?
No.
456
What are the two circumstances under which a QME is allowed to provide medical treatment to an injured worker?
The injured worker requests it. (For instance, a QME sees an injured worker. The injured worker then freely chooses the QME as their primary treating provider (PTP). The QME must then excuse themselves from future QME evaluations with that injured worker).Under emergency situations.
457
How is the term 'M.T.U.S.' defined?
Medical Treatment Utilization Schedule
458
What is the definition of the Medical Treatment Utilization Schedule (MTUS)?
The treatments adopted by the DWC’s Administrative Director.
459
When a QME is required to deliver emergency treatment, should they follow the Medical Treatment Utilization Schedule (MTUS) or the guidelines of the American College of Occupational and Environmental Medicine (ACOEM)?
No. The QME can administer any necessary emergency treatment.
460
What is the primary purpose of a medical-legal report generated by a QME?
To prove or disprove an aspect of a contested claim. Disputes can be about compensability, permanent or temporary disability, apportionment, permanent and stationary status, etc.
461
Who relies on a QME’s medical-legal report?
Insurance companies, insurance adjusters, attorneys, worker’s compensation judges, other QMEs, other AMEs, and clinicians treating the injured worker.
462
What is the primary responsibility of a QME?
To resolve disputes without bias towards either party (the defense attorney/ insurance company or the applicant’s attorney/ injured worker).
463
Is a QME acknowledged as an expert or expert witness?
Yes. The QME’s opinions in the medical-legal report are used as “expert testimony” during depositions, employment lawsuits, third party lawsuits, disability determinations, and treatment determinations.
464
In what contexts can a QME deliver medical-legal testimony?
The QME will serve as an expert witness and provide medical-legal testimony at a deposition or a WCAB hearing (Workers’ Compensation Appeals Board).
465
What specific information must a QME include in their report for it to be admissible as evidence in a dispute under Labor Code section 5703?
Somewhere in the report, the QME must state, “There has not been a violation of Section 139.3 and that the contents of this report are true and correct to the best of my knowledge. This statement is made under penalty of perjury.”
466
Can a QME request or accept any form of compensation for medical-legal expenses, such as rebates, refunds, or discounts, if the amount surpasses the fees permitted under Labor Code section 5307?
No. Labor Code section 5307 bars the QME from receiving compensation from a party or any source that is in addition to payment for the report.
467
Is it legal for a QME to refer an injured worker for clinical lab services or related medical services if the physician or their immediate family holds a financial interest in the entity providing the service?
No. This is known as “self-referral” and this is illegal. This is grounds for disciplinary action.
468
Who has the authority to issue medical-legal reports within the California workers' compensation system?
QMEs, AMEs, and Primary Treating Physicians.
469
If a QME misses the reappointment deadline for two years and fails to pay the fee, what actions must they take before re-registering?
The QME must take and pass the QME Competency Examination.
470
What are five potential reasons that could lead to disciplinary action against a QME?
Self-referral (the QME tells injured workers to get treatment through the QME’s private medical practice).Ex Parte communications.Lack of availability for evaluation appointments within a reasonable time period (60 days).Submitting late reports.Prepares reports that are not up to standard.
471
How is the Medical Treatment Utilization Schedule (MTUS) described or defined?
The treatments adopted by the DWC’s Administrative Director.
472
When delivering emergency treatment, should a QME follow the Medical Treatment Utilization Schedule (MTUS) or the guidelines from the American College of Occupational and Environmental Medicine (ACOEM)?
No. The QME can administer any necessary emergency treatment.
473
Who relies on the conclusions presented in a QME’s medical-legal report?
Insurance companies, insurance adjusters, attorneys, worker’s compensationjudges, other QMEs, other AMEs, and clinicians treating the injured worker.
474
What is the primary role or duty of a QME?
To resolve disputes without bias towards either party (the defense attorney/instance company or the applicant’s attorney/ injured worker).
475
In what types of settings is a QME permitted to provide medical-legal testimony?
The QME will serve as an expert witness and provide medical-legal testimony at a deposition or a WCAB hearing (Workers’ Compensation Appeals Board).
476
Within the California workers' compensation system, who is granted the authority to issue a medical-legal report?
QMEs, AMEs, and Primary Treating Physicians.
477
If a QME fails to pay their reappointment fee for two years, what steps must they follow to become eligible for re-registration?
The QME must take and pass the QME Competency Examination.
478
List five scenarios that might result in disciplinary action being taken against a QME.
Self-referral (the QME tells injured workers to get treatment through the QME’s private medical practice).Ex Parte communications.Lack of availability for evaluation appointments within a reasonable time period(60 days).Submitting late reports.Prepares reports that are not up to standard.
479
How should courts interpret workers' compensation laws in California?
Liberally.
480
What is the reason behind the courts’ liberal interpretation of California's workers' compensation laws?
With the purpose of extending work-comp laws’ benefits for the protection of persons injured in the course of their employment.
481
When is an evaluation for permanent disability typically conducted?
When an injured worker is permanent and stationary (also known as maximal medical improvement, MMI).
482
How is the term 'permanent and stationary' defined?
When the worker’s condition has reached maximal medical improvement (M.M.I.); the employee’s condition is well stabilized and is unlikely to change substantially within the next year, with or without medical treatment.
483
What are the two criteria that establish permanent and stationary status?
The worker’s condition has reached maximum medical improvement (MMI).The worker’s condition is unlikely to substantially change within the next year with or without medical treatment.
484
What are the five different categories of benefits under workers' compensation?
Medical treatment.Temporary disability benefits.Permanent disability benefits.Death benefits.Supplemental job displacement benefits (vocational rehabilitation).
485
If a QME learns that the injured worker's impairment/disability resulted from non-work-related activities, should this be included in the QME report?
Yes. The QME should note this in the injured worker’s history. Apportionment may be required.
486
If an injured worker was considered Permanent & Stationary before 1/1/2005, what three factors determine their Permanent Disability rating?
Subjective factors of disability.Objective factors of disability.Work restrictions.
487
How is substantial evidence defined in formal terms?
Relevant evidence that a reasonable mind might accept as adequate to support a conclusion.
488
What does substantial evidence mean in everyday language?
Reasonable medical probability.
489
As evaluators, what role do they play in ensuring the quality of QME and AME reports used to resolve disputes?
The task of an evaluator is to provide a report which constitutes substantial evidence, and can be used to resolve disputes about medical issues.
490
What percentage of certainty does a QME imply when using the term "reasonable medical probability"?
Reasonable medical probability is 51% or greater.
491
How is a medical opinion defined?
Any opinion that a physician provides in speech or writing.
492
For a medical opinion to qualify as substantial evidence, what must it be based on?
Reasonable medical probability.
493
What criteria are used for making medical decisions during a QME evaluation?
Reasonable medical probability. The QME must have greater than 51% certainty of their opinion.
494
How can a QME guarantee that their opinions meet the standard of "substantial evidence"?
A QME must conduct an adequate and comprehensive examination of the injured worker.
495
What steps can a QME take to demonstrate that their written opinions in a medical report are substantial evidence?
The QME’s report will be considered substantial evidence if it sets forth the reasoning behind the QME’s opinions, not merely the conclusions.
496
How much confidence or probability must a QME have to allocate apportionment?
Reasonable medical probability.
497
List the four situations in which a QME’s medical opinion does not meet the criteria for "substantial evidence."
Based on facts no longer germane.Based on inadequate medical histories or examinations.Based on incorrect legal theories.Based on guess, conjecture, surmise, and/or speculation.
498
To qualify as substantial evidence, must a medical report include the reasoning behind the physician's opinion rather than just conclusions?
Yes.
499
When drafting a QME report, the QME refrains from using uncertain terms such as 'possibly' or 'maybe.' What alternative approach should they take?
Give direct and definite opinions supported by evidence and reasoning.
500
What methods or criteria should a QME rely on to determine the credibility of physical exam outcomes and test results?
Entire range of the QME’s clinical skill and judgement.
501
What factors are considered to determine a suitable impairment rating for a specific injury or illness?
A rating that takes into account all impairments, not only the primary body part or organ system impacted, but the full impact of the illness and injury and its treatment.
502
Why are physicians mandated by the Division of Workers' Compensation (DWC) to use the AMA guidelines when evaluating impairments in injured workers?
To provide uniformity when calculating disability awards.
503
How is the term 'strict rating' defined in the context of impairment evaluation?
A strict rating refers to the textbook, standard and customary use of the AMA guides to determine an impairment rating.
504
If a QME identifies two different methods for calculating impairment for a specific injury, which one should be considered the most accurate for the report?
The method that gives the highest impairment rating is the most accurate rating.
505
In a Permanent and Stationary (P&S) report, what does the abbreviation WPI represent?
Whole person impairment. This is the same as permanent impairment.
506
What course of action should a QME take when an impairment is absent from the AMA guidelines?
Physicians are instructed to, “use clinical judgment, comparing measurable impairment resulting from the unlisted condition to measure impairment resulting from similar conditions with similar impairment.”
507
What term is used when a QME compares an unlisted impairment to a listed one for the purpose of rating?
Rating by analogy.
508
Which landmark case provided the legal foundation for using 'rating by analogy'?
Almaraz-Guzman.
509
In the context of rating by analogy or an Almaraz-Guzman analysis, does the derived impairment rating need to align closely with the original strict rating?
No, the rating by analogy can provide a different impairment rating.
510
What criteria must be fulfilled when applying rating by analogy or conducting an Almaraz-Guzman analysis?
The QME must first calculate the strict rating. Then, an alternative impairment is calculated by analogy using an impairment value contained within a chapter of the AMA Guides. The more favorable rating is then the final rating.
511
Is a rating by analogy or an Almaraz-Guzman analysis required for every case that is deemed Permanent and Stationary?
No.
512
How does the AMA Guides define anatomic loss?
Damage to an organ system or body structure.
513
What is the definition of functional loss according to the AMA Guides?
A change (decrease) in function for the organ or body system.
514
What process was followed to establish the impairment criteria outlined in the AMA Guides?
Through scientific evidence, consensus of chapter authors, and medical specialty society recommendations.
515
How many chapters of the AMA Guides are available for a QME to reference when rating an injured worker's impairments?
As many as necessary to accurately rate permanent impairment.
516
BONUS: When employing rating by analogy or an Almaraz-Guzman analysis, what four steps is a QME expected to follow?
Provide a strict rating per the AMA Guides.Explain why the strict rating does not accurately reflect the injured worker’s disability.Provide an alternate rating using the four corners of the AMA Guides.Explain why the alternate rating more accurately reflects the injured worker’s level of disability.
517
What aspects must a QME assess and rate when assigning an impairment rating for an illness or injury, such as cancer?
The QME must evaluate and report all impairments resulting from the illness or injury including effects from treatment (impairments from chemotherapy, impairments from radiation, impairments from mastectomy).
518
Is it appropriate for a QME to include subjective complaints when calculating impairment ratings?
Yes. The QME should collect a thorough history (subjective information) and perform a physical examination.
519
What is the process for a QME to convert an upper extremity impairment into a whole person impairment rating?
Multiple the upper extremity impairment by 0.6 (memory aid: hands are worth more than feet).
520
What method does a QME use to translate a lower extremity impairment into a whole person impairment?
Multiple the lower extremity impairment by 0.4 (memory aid: hands are worth more than feet).
521
In the case of a worker who contracted HIV through their job, how should impairment be calculated once their HIV is well-controlled and they have reached maximum medical improvement?
This is a trick question. The QME should not assign impairment simply because of a diagnosis or a disease. There has to be impairment. In this case, whole person impairment would be 0%.
522
For a worker with well-managed diabetes who has reached maximum medical improvement, what is the process for calculating impairment?
This is a trick question. The QME should not assign impairment simply because of a diagnosis or a disease. There has to be impairment.
523
What was the purpose behind the development of the combined values chart in the AMA Guides?
So that multiple impairment calculations do not exceed 100% whole person impairment.
524
If a worker has impairments affecting the right hand, left knee, and cervical spine, how should the QME calculate the total whole person impairment?
The QME should use the Combine Values Chart on page 604 of the AMA Guides.
525
BONUS: If impairments in both the left and right hands create a synergistic effect leading to a greater overall impairment than if different body parts were affected, what landmark case allows the QME to add these impairment ratings instead of combining them?
The Kite case. The Kite Case allows for the adding of impairment ratings for different body parts. “Adding” 8% and 4% results in 8% + 4%= 12%. “Combining” 8% and 4% (per the Combined Values Chart on page 604 of the AMA Guides) equals 10%. Notice how “adding” yields a higher impairment value.
526
How is the term 'chronic pain' defined in the context of impairment evaluation?
Any pain lasting more than 6 months after the date of injury.
527
If a QME does not identify any ratable impairments but the injured worker reports ongoing pain, is it permissible for the QME to assign up to 3% whole person impairment for chronic pain?
No. The pain “add-on” can only be added on top of ratable impairment.
528
If a QME assigns a 1% impairment rating but the worker experiences additional pain beyond that level, can the QME allocate up to 3% whole person impairment for chronic pain?
Yes. Because there is ratable impairment, 1 - 3% whole person impairment can be added on top of this.
529
When a QME determines that pain further restricts the injured worker's daily activities beyond the initial impairment rating, how much additional impairment may the QME assign as an 'add-on'?
1-3% whole person impairment.
530
If a QME concludes that an injured worker experiences chronic, severe pain not reflected in the impairment rating, what additional actions can the QME take?
The QME can assign 1-3% additional permanent impairment for pain.
531
If a QME finds no specific impairments but the worker reports headache pain, is it appropriate to assign an impairment rating for the headaches?
Yes. 1-3% whole person impairment can be added for headaches in the absence of other impairments; this is unique to headaches.
532
True or False: To ensure accuracy, a QME must consider how the impairment affects the worker's daily living activities when providing an impairment rating.
True.
533
Does the ability to work fall under the category of Activities of Daily Living?
No.
534
Senate Bill 899 (SB899) specifies that the most effective way to measure impairment is based on limitations to which aspects of the worker's functionality?
Activities of Daily Living (ADLs).
535
Before January 1, 2005, what standard or normal values were applied for assessing range of motion?
Packard Thurber’s “Estimated Average Normal” from 1960.
536
Starting January 1, 2005, what benchmarks must a QME use when comparing the range of motion in an extremity?
The QME must compare findings to the normal values found in the AMA Guides as well as to the opposite, unharmed/uninjured extremity.
537
What findings are categorized as 'objective findings' by the Division of Workers' Compensation (DWC)?
Lab and diagnostic tests, EMG/NCS electrodiagnostic testing, x-ray’s, MRI’s, CT’s.
538
If a worker exhibits minimal multilevel degenerative changes in a lumbar spine MRI but does not require treatment or face work or activity limitations, how should their lumbar spine impairment be assessed?
There is no ratable impairment. 0% Whole Person Impairment (WPI).
539
Identify four situations that result in a 100% total disability rating.
Loss of both eyes/ all sight.Loss of both hands/ complete use of hands.Total paralysis.Brain injury resulting in mental incapacity or insanity.
540
What are the responsibilities of an employer when it comes to the care of injured employees?
The employer is responsible for any disability directly caused by a work injury.
541
If a worker has a non-industrial condition that impedes recovery from an industrial injury, what obligations does the employer have?
The employer must pay for medical treatment for the non-industrial condition so that the injured worker can receive necessary medical care for the industrial injury. An example of this is if there is non-industrial, uncontrolled diabetes. If an injured worker needs an ankle surgery, but cannot until the diabetes is under control, then the employer must pay for the costs of helping to get the worker’s diabetes under control for surgery.
542
In the case of a morbidly obese worker who sustains an industrial knee injury and is required to lose weight before surgery, is the employer liable for covering the costs of a sleeve gastrectomy if it is deemed necessary?
Yes. The employer must pay for medical treatment for the non-industrial condition so that the injured worker can receive necessary medical care for the industrial injury.
543
Can an employer be held accountable for a worker’s disability that stems from factors that occurred either prior to or following an industrial injury?
No.
544
In what ways does apportionment serve to protect an employer from full liability?
So that the employer is not forced to pay for disability that is not the direct result of an industrial injury.
545
How is an employer's financial responsibility determined when a portion of the disability is work-related and another portion is not?
The employer shall only be liable for the percentage of permanent disability directly caused by the injury arising out of, and occurring in, the course of employment.
546
What is an alternative term used for apportionment?
“Causation of disability.”
547
What is a synonym for the term 'causation of disability'?
Apportionment.
548
How are the terms 'apportionment' and 'causation of disability' defined?
“Causation of disability”/ apportionment deals with a determination of accurate permanent disability and apportionment between industrial and non-industrial factors.
549
What are the valid factors upon which apportionment can be based?
“Causation of permanent disability.”
550
Is it mandatory for all QME reports to address apportionment to be deemed complete?
Yes, all QME reports must include an apportionment determination in order to be considered complete on the issue of permanent disability. However, there is a massive exception: it is unnecessary to provide an opinion about apportionment of permanent disability if the injured worker is not Permanent and Stationary/ has not reached MMI (Maximal Medical Improvement).
551
Must a QME discuss apportionment if the case has not yet reached a permanent and stationary status?
No. Only when the injured worker has reached a point of Maximal Medical Improvement (MMI) / Permanent and Stationary does apportionment need to be addressed.
552
Is it required to offer an opinion on the apportionment of permanent disability if the injured worker has not achieved a permanent and stationary condition?
No, it is unnecessary to provide an opinion about apportionment of permanent disability because the injured worker is not permanent and stationary.
553
During a QME evaluation, if the injured worker has not yet attained maximal medical improvement (MMI) or permanent and stationary status, should the QME still issue a report that includes opinions on apportionment and impairment rating?
No. Impairment (permanent impairment) and apportionment are only addressed at the time of maximal medical improvement (MMI) / Permanent and Stationary.
554
What methods can a QME utilize to determine apportionment?
By finding what approximate percentage of the permanent disability was caused by the direct result of injury arising out of and occurring in the course of employment and what approximate percentage of the permanent disability was caused by other factors both before and subsequent to the industrial injury, including prior industrial injuries.
555
In the case of a worker who sustained a lumbar spine injury resulting in permanent impairment, with an MRI revealing minimal multilevel degenerative changes and no history of lumbar spine issues, what percentage should be apportioned to pre-existing degenerative changes?
0%. It is speculation to assume there was impairment based on a diagnosis of “degenerative changes.” Simply having “degenerative changes” (diagnosis) does not mean that there was pre-existing impairment. Impairment is different than a diagnosis.
556
Who bears the responsibility of proving apportionment of the impairment?
The employer (also known as the Defense party, the Defense, the Defense Attorney, or the Adjuster).
557
When apportionment is necessary, is it the QME's role to manually subtract the apportioned amount from the overall impairment rating?
No. Apportionment is given as a stand-alone percentage.
558
If a QME identifies secondary psychological disorders, sleep disorders, and erectile dysfunction, but they are not catastrophic, can the QME still assign impairment ratings?
No.
559
If a worker sustained a left elbow injury in 2000 and was rated with a 10% whole person impairment, then reinjured the same elbow in 2020 with a 20% impairment rating, what steps should a QME take to determine apportionment?
The QME should assign apportionment because permanent impairments are presumed to last forever.
560
Is it within a physician's authority to apportion the cause of the injury?
No. The cause of the injury is irrelevant. (For instance, the fact that a faulty machine caused the injury is irrelevant). Causation of the injury deals with whether or not an injury occurred on the job).
561
Can a physician apportion the cause of the worker's permanent impairment or disability?
Yes. A physician must determine what portion of the permanent impairment/ disability, if any, was caused by factors other than the work injury.
562
Does a QME’s apportionment of the cause of injury constitute substantial evidence?
No, this report would not be substantial evidence. The cause of the injury is irrelevant and a QME may not apportion the “causation of the injury.”
563
If a worker drops a barrel on his foot at work due to a loss of grip in his previously injured right hand, can a physician apportion the injury to the pre-existing hand injury? Is this relevant to the QME's evaluation?
No. The cause of the injury is irrelevant and a QME may not apportion the “causation of the injury.”
564
Is a QME responsible for apportioning treatment?
No. Only permanent disability is apportioned.
565
Does a QME have the duty to apportion work restrictions?
No. Only permanent disability is apportioned.
566
True or false: Medical treatment for an injured worker should be apportioned based on both industrial and non-industrial factors, similar to how permanent disability is handled.
False.
567
What three elements must be included in a QME report for it to be considered substantial medical evidence regarding apportionment?
The QME report must disclose familiarity with the concepts of apportionment.The QME report must describe, in detail, the exact nature of the apportionable disability.The QME report must set forth the basis for the opinion/the reasoning.
568
What are the three essential components of a medical opinion in apportionment determinations?
Disclose familiarity (knowledge and understanding) with the concepts of apportionment.Describe in detail the exact nature of the apportionable disability.Set forth the basis for the opinion.
569
If a worker undergoes surgery for a work-related injury but suffers a stroke due to complications, and it is found that the worker had pre-existing conditions such as atrial fibrillation, strokes, TIA’s, CHF, hypertension, and diabetes, does the QME need to apportion the cause of the stroke to these pre-existing risk factors?
No. The cause of the injury is irrelevant. Remember, the stroke is the injury. Causation of the injury deals with whether or not an injury occurred on the job or, as in this case, if an injury is the result of a work-related injury.
570
When a worker suffers a stroke due to complications during surgery for a work injury, and the worker had pre-existing conditions like atrial fibrillation, previous strokes, TIA’s, CHF, hypertension, and diabetes, should the permanent disability from the stroke be apportioned to these pre-existing conditions?
Possibly. Apportionment would only be required if the previous strokes and TIA’s had resulted in permanent impairments to the injured worker (such as, the worker had leg weakness or the inability to use their left arm). The defense party would need to prove to the QME that the injured work had pre-existing permanent impairments. On the other hand, if injured worker’s present permanent disability was entirely the result of the stroke caused by the work-related surgery, then no apportionment is required. Simply having a medical history of “previous TIA’s” and “previous strokes” does not mean there was permanent impairment.
571
Can a QME apportion a work-related injury to risk factors if those factors made the injury more likely?
No. QMEs may not apportion to risk factors. Risk factors relate to the cause of an injury and the cause of the injury is irrelevant. A QME may not apportion the causation of the injury.
572
When determining if a work-related activity aggravated a pre-existing chronic medical condition, should a QME consider industrial risk factors?
No. Causation of injury is not based on risk factors but by whether or not industrial exposure contributed by 1% or more to the need for medical care.
573
A worker who sustained a lumbar compression fracture at work, with normal MRI and x-ray results one month prior, had the cause of the injury apportioned to their age of 98. Is this appropriate? Additionally, the QME apportioned permanent disability to risk factors; is this acceptable?
No and no. The QME may not apportion causation of the injury. In addition, the QME may not apportion permanent disability to risk factors, including to gender or age-based risk factors. A factor that may increase the risk of a particular kind of injury or condition is not evidence that the factor actually caused a portion of an individual worker’s permanent disability.
574
Is it permissible for a QME to apportion permanent disability based on the worker’s increased risk of sustaining an injury?
No. QMEs may not apportion permanent disability based on risk factors. Risk relates to chance of an injury occurring (and this is related to causation of the injury). Risk of injury is not the same as cause of disability. “Apportionment must be based on actual evidence as to the individual worker, not based on categorical risk factors and assumptions based on those factors.” Apportionment of permanent disability must be based on actual evidence as to the individual worker, not based on categorical risk factors and assumptions based on those factors.
575
If a worker with a pre-existing lumbar compression fracture suffers a work-related lumbar compression fracture in the same vertebral body, and the QME apportions the permanent disabilities to the pre-existing condition that weakened the bones, is this apportionment appropriate?
Yes. There is evidence that a pre-existing condition contributed to the permanent disability/ impairment.
576
Provide examples of categories that are protected against discrimination.
Gender, age, race, religion, sexual preference, whether or not the worker is represented by an attorney, and national origin.
577
Is it acceptable to reduce a worker's permanent disability compensation due to discrimination?
No. QMEs are required to provide medical opinions that are fair, and partial, and based on their best medical judgment.
578
Provide an example of unlawful apportionment based on an age-related risk factor.
“An injured worker, 1 year prior to the work-injury, had a normal lumbar spine Xray and normal lumbar spine MRI. Due to a work-injury, the worker now has permanent disability. On the basis that the worker was 80 years old, 50% of his permanent disability to his spine is nonindustrial and 50% is work-related.”
579
What makes apportionment to an age-based risk factor illegal?
Because there is no evidence that there was a pre-existing medical condition that were causing permanent impairments.
580
Offer an example of improper apportionment based on gender-related risk factors.
“On the basis that the worker is 60 and postmenopausal, 50% of her permanent disability for her heart is nonindustrial and 50% is related to the work-injury.”
581
Why is it illegal to apportion based on gender-related risk factors?
Because there is no evidence that there were pre-existing medical conditions that were causing permanent impairments.
582
If a 98-year-old worker sustains an L4/5 disc herniation with radiculopathy at work, but medical records show a previous herniation at the same location from another job, what should the QME consider when determining apportionment, and what is irrelevant?
The worker’s age should have no bearing on apportionment; it is illegal to discriminate based on age. The fact that the worker had a pre-existing condition is key and absolutely should be apportioned. For example: “25% of the workers disability is related to pre-existing radiculopathy. 75% of the workers disability is related to the injury from work.”
583
How is a dispute over compensability, also referred to as Labor Code section 4060, defined?
This is a dispute over whether work caused an injury recognized under the workers’ compensation laws of California. This is also known as a dispute over “causation of the injury.”
584
If a worker asserts that an injury happened at work but the claims administrator denies the claim, stating the injury was not work-related, is it possible to request a QME?
Yes. This is a dispute over compensability (also known as Labor Code section 4060). This is also known as a dispute over “causation of the injury.”
585
Under what circumstances is Labor Code section 4060, involving a dispute over compensability, applied?
Any time after the claim form is filed, but before the claim or any body part has been accepted by the claims administrator.
586
After a claims administrator has accepted responsibility for any body part, can either party request a QME under Labor Code section 4060 concerning compensability?
No. Once the claims administrator has accepted any body part, a QME panel cannot be requested based on compensability (also known as Labor Code section 4060).
587
When a worker claims two injuries and the claims administrator accepts one but disputes the work-relatedness of the other, can a QME panel be requested under Labor Code section 4060 for compensability?
No, because the claims administrator already accepted 1 body part. Once 1 body part is accepted as a work-injury, a QME panel cannot be requested based on compensability (also known as Labor Code section 4060).
588
If a worker claims two injuries, and the claims administrator only accepts one and rejects the second as non-work-related, preventing a QME panel request under Labor Code section 4060, what alternative methods can be used to resolve the dispute?
Once 1 body part is accepted as a work-injury, a QME panel cannot be requested based on compensability (also known as Labor Code section 4060). Thus, the dispute regarding compensability of the 2nd injured body part must be resolved under Labor Code section 4062 (the Labor Code’s “catch-all” section).
589
If a QME performed an evaluation to address a compensability issue under Labor Code section 4060, but the claims administrator had already accepted one of the four body parts claimed to be injured, was the QME appropriately requested for compensability?
No. The QME should not have been requested for compensability (also known as Labor Code section 4060) because the claims administrator had already accepted 1 body part.
590
If a QME panel was requested for compensability, a QME was selected, an evaluation took place, and a report was issued, but it was later discovered that the claims administrator had already accepted one body part as work-related, who is responsible for the QME fees?
Neither party is liable for paying the QME fees. A QME panel should not be requested based on compensability (also known as Labor Code section 4060).
591
When a claims administrator is uncertain whether the employer is responsible for an injured worker's injury, what two actions must the claims administrator take for an unrepresented injured worker?
Send the injured worker a notice that the claim is denied and they may or may not request a QME.Send the injured worker a notice that the claims administrator requests an examination to further investigate compensability (Labor Code section 4060).
592
If a QME discovers that an injured worker is claiming symptoms that have been present for over a year before filing a Workers’ Compensation claim, is the worker eligible to have the claim accepted as work-related?
Yes.
593
For an injured worker claiming a cumulative trauma industrial injury, what is considered the date of injury?
Date of injury in cases of cumulative injuries is that date upon which the employee first suffered disability therefrom and either knew, or in the exercise of reasonable diligence should have known, that such disability was caused by his/her present or prior employment.
594
When an injured worker, who has held multiple similar jobs in succession as a full-time logger, realizes they have sustained a work-related injury that requires treatment, how does the QME establish the Date of Injury?
The date when the injured worker first realized there was a work-related injury.
595
If an injured worker, who has held multiple similar jobs as a full-time logger, has a Date of Injury associated with their last employer but the injury is a result of cumulative trauma, could the previous employers be liable for the impairment/permanent disability, and how should the QME address this?
Yes, prior employers may be liable for the impairment. This should be addressed at the time the worker reaches maximal medical improvement/ Permanent and Stationary with apportionment of permanent disability/impairment. Of note, the defense has the burden of proof to show that the injured worker had pre-existing permanent impairments.
596
If an off-duty employee was asked by her supervisor to give visitors a tour of the factory and slipped, sustaining an injury, is there industrial causation, and if so, what is the nature of the causation?
Yes. The injury Arose Out of Employment (A.O.E.).
597
If an on-duty employee was injured by a saw while performing his regular job of cutting trees, is there industrial causation, and if so, what is the nature of the causation?
Yes. The injury occurred during the Course Of Employment (C.O.E.).
598
If an off-duty employee was injured in a car accident while driving home, is there industrial causation, and if so, what is the nature of the causation?
No. A normal commute to and from work is not work-related.
599
If an injured worker contracts HIV while on the job, what protections must be provided to the injured worker?
Maintain a fictious name file with a Workers’ Compensation Judge.Follow all usual medical confidentiality laws.
600
If a worker sustains a paper cut and sees a doctor, who then clears the worker to return to work without restrictions, how is this situation categorized, and should a formal claim be filed?
This is considered a minor first aid incident. No claim should be filed. First aid involves one-time treatment and follow up visits.
601
What is the minimum requirement for a claim to be considered compensable?
If an industrial injury triggered the need for medical care and treatment by 1%, then it’s a compensable claim.
602
How is the term 'aggravation' defined?
An aggravation is defined as additional impairment above and beyond the worker’s baseline level of impairment. Stated another way, a medical condition may be present already, but some event/ (work) exposure makes it worse.
603
What are three essential categories of information required to assess whether work caused industrial aggravation of a chronic, pre-existing medical condition?
An understanding of the natural history of the pre-existing medical condition.A chronological listing of all diagnostic data related to the pre-existing medical condition.A chronological history of symptoms and functional limitations related to the pre-existing medical condition.
604
If an injured worker previously sustained an injury resulting in permanent impairment/disability and then experienced an aggravation of that injury, is this considered a compensable claim, or should the QME conclude that the aggravation is non-industrial?
An aggravation is defined as additional impairment above and beyond the worker’s baseline level of impairment. Thus, the injury made the impairment at least 1% worse so this is a compensable claim.
605
If a worker's pre-existing medical condition was aggravated by work-related activities, is this injury compensable?
Yes. Under the Labor Code this is a work-related compensable injury.
606
How is the term 'exacerbation' defined?
An exacerbation or “flare up” is a temporary increase in symptoms that does not permanently increase the worker’s baseline level of pain.
607
If an injured worker, who had a previous injury resulting in permanent impairment/disability, experiences an exacerbation of that injury, is this a compensable claim, or should the QME determine that the exacerbation is non-industrial?
An exacerbation is a temporary increase in symptoms. Thus, this flare up injury is not a compensable claim.
608
Within the workers' compensation system, is the act of proving or disproving a contested claim considered a valid 'medical-legal expense'?
Yes.
609
Can a compensable injury result from both a specific event and cumulative trauma within the same case?
Yes.
610
Can a QME be requested when there is a dispute regarding the existence or extent of permanent disability?
Yes. This is a permanent disability dispute (also known as Labor Code section 4061).
611
Can parties request a QME if there is a disagreement over the necessity of future medical care?
Yes. This is a permanent disability dispute (also known as Labor Code section 4061).
612
Is it possible for future medical care to extend beyond two years?
Yes.
613
When a QME is the first physician to determine that a worker has reached Permanent and Stationary status during the QME evaluation, what additional requirements must be met?
The QME must complete the Return-to-Work and Voucher Report and serve it to the claims administrator and the employee along with the final QME report.
614
What factors or conditions does a QME evaluate?
The QME rates permanent impairment. The QME provides permanent impairment ratings.
615
What else does a permanent impairment rating determine?
A determination regarding the extent of injury.
616
Is a QME responsible for providing permanent disability ratings?
No, the QME does not rate permanent disability. The QME does not provide permanent disability ratings. It is important to remember that permanent disability and permanent impairment are two different things.
617
Is it within a QME's responsibilities to rate permanent disability?
No, the QME does not rate permanent disability. The QME does not provide permanent disability ratings. It is important to remember that permanent disability and permanent impairment are two different things.
618
When a QME determines that an injured worker has reached maximal medical improvement (MMI) / Permanent & Stationary status and the date of injury occurred after January 1, 2005, what standard must be used for the impairment rating?
The AMA Guides 5th edition. (No other edition may be used.)
619
Is a QME with a specialty in acupuncture permitted to issue opinions on impairment ratings and permanent disability?
No.
620
If an Acupuncture QME is presented with contested issues of impairment and permanent disability, how should they proceed?
The Acupuncture QME should answer all issues within their scope but request another QME address permanent disability and provide ratings for permanent impairments.
621
What is the critical date to keep in mind when determining the standard a QME should use for conducting an impairment rating?
Whether the date of permanent and stationary was before or on/after January 1, 2005.
622
What guidelines are used to rate impairment for an injured worker who reached Permanent and Stationary status before January 1, 2005?
The 1997 Permanent Disability Rating Schedule (P.D.R.S.).
623
What method is used to determine impairment ratings for injuries that occurred before January 1, 2005?
April 1997’s Permanent Disability Rating Schedule.
624
Do the impairment ratings found in the AMA Guides assume that the injured worker’s injuries are permanent and stationary or that they have reached maximal medical improvement (MMI)?
Yes. These are permanent impairment ratings.
625
What criteria are used to rate impairment for injuries that occurred on or after January 1, 2005 and have reached Permanent and Stationary status?
The American Medical Association (A.M.A.) Guides to Evaluation of Permanent Impairment 5th edition (abbreviated as AMA Guides).
626
What standards are applied to determine impairment ratings for injuries occurring on or after January 1, 2005?
AMA Guides to the Evaluation of Permanent Impairment, 5th Edition.
627
If an injured worker is approaching Permanent and Stationary status but the QME requires additional tests and imaging studies to issue an impairment rating, what steps should the QME take?
It is legal for the QME to decline issuing a permanent impairment rating until the tests and imaging studies are completed and then reported to the QME.
628
If an injured worker requests additional medical treatment, can the QME resolve this dispute regarding the need for current treatment?
No. This would be resolved through the Independent Medical Review process or the Utilization Review process.
629
As of what date, irrespective of the date of injury, should QMEs cease to resolve disputes concerning the current need for medical treatment?
July 1, 2013.
630
True or false: Beginning January 1, 2013 for new injuries, and July 1, 2013 for all injuries, QMEs no longer resolve disputes related to the current need for medical treatment.
True.
631
When a worker is represented by an attorney, how many days does either party have to object to the medical determination made by the injured worker’s primary treating physician (PTP)?
20 days.
632
If a worker is unrepresented, how many days does either party have to object to a medical determination made by the injured worker’s primary treating physician (PTP)?
30 days.
633
Is it permissible for a party to request a QME in cases of dispute regarding whether an injured worker is temporarily disabled?
Yes. This falls under Labor Code Section 4062 (the Labor Code’s “catch-all” section).
634
Can a QME be requested to address disputes concerning whether or not an injured worker has work restrictions?
Yes. This falls under Labor Code Section 4062 (the Labor Code’s “catch-all” section).
635
What is the intended purpose of prophylactic work restrictions?
To ensure that the injured worker does not sustain further injury.
636
Can a QME be requested in cases of dispute over whether new or additional disability has developed following the original injury?
Yes. This falls under Labor Code Section 4062 (the Labor Code’s “catch-all” section).
637
Is it permissible for a party to request a QME to resolve a dispute about whether an injured worker's condition has reached Permanent and Stationary status or MMI?
Yes. This falls under Labor Code Section 4062 (the Labor Code’s “catch-all” section).
638
Can a QME be requested to resolve disputes regarding whether a newly added body part is a compensable consequence of the industrial injury?
Yes. This falls under Labor Code Section 4062 (the Labor Code’s “catch-all” section).
639
Under LC4662, how many days are payers given to settle a medical-legal expense?
60 days.
640
If an injured worker requests additional medical treatment, can the QME resolve the dispute under the 'catch-all' provision?
No. This would be resolved through the Independent Medical Review process or the Utilization Review process.
641
Can disputes concerning current medical care be resolved through a QME under Labor Code section 4062?
No. Senate Bill 863 (SB863) established the Independent Medical Review system to deal with current medical care disputes.
642
If an injured worker believes that their current treatment was wrongfully denied by insurance, can this dispute be resolved by a QME?
No. Senate Bill 863 (SB863) established the Independent Medical Review (I.M.R.) system to deal with current medical treatment disputes.
643
Can an injured worker bring a dispute to a QME if they believe that their current treatment has been delayed by the insurance company?
No. Senate Bill 863 (SB863) established the Independent Medical Review system to deal with current medical treatment disputes.
644
If an employee disagrees with substantial aspects of their primary treating physician's disability evaluation, can the employee request a QME evaluation?
Yes.
645
If an employer disagrees with significant elements of the primary treating physician's disability evaluation for an injured worker, can the employer request a QME evaluation?
Yes.
646
Can an employer request a QME evaluation if they disagree with substantial portions of the primary treating physician's disability evaluation for an injured worker?
Yes.
647
Who is eligible to request a QME?
An employee (and their attorney, if any) or an employer (and their attorney, if any).
648
Under what circumstances is it permissible for a licensed physician who is not a QME to serve as an AME?
When an injured worker is represented by an attorney and both parties (the injured worker’s attorney and the insurance adjuster/defense attorney) agree to use that physician.
649
If a doctor, who is also a QME, treats a patient and the patient later suffers a contested work injury, is the doctor allowed to act as the QME in this case?
No.
650
After a QME evaluates an injured worker, the worker voluntarily selects the QME as their primary treating provider (PTP). Can the doctor later perform a QME re-evaluation for the same worker?
No. The injured worker will need to select a different QME.
651
Which organization in California is tasked with creating a panel of three QME physicians?
The Division of Workers’ Compensation (DWC) Medical Unit.
652
How many doctors are included in a QME panel?
Three.
653
How is the term 'unrepresented injured worker' defined?
An injured worker who is not represented by an attorney.
654
Is it possible for an unrepresented injured worker to resolve a medical dispute by using an Agreed Medical Evaluator (AME)?
No. An unrepresented injured worker cannot be offered and cannot accept an offer to resolve a medical dispute using an AME.
655
When an injured worker is unrepresented, which party has the initial right to request a QME panel using form 105?
The injured worker. Remember, there is inherent power in requesting a QME panel because the party that completes the request gets to select the specialty of the QME.
656
For an unrepresented injured worker, who has the first opportunity to choose the specialty of the physicians on the QME panel?
The injured worker. This selection is a part of requesting a QME panel (form 105).
657
When is a claims administrator allowed to request a QME panel (form 105) for an unrepresented injured worker?
The claims administrator may submit the QME request form (form 105) when the employee has not submitted the QME request form (form 105) within 10 days after the employer has furnished the QME request form (form 105) to the employee and requested the employee to submit the QME request form (form 105).
658
If a claims administrator provides form 105 to an unrepresented injured worker and asks them to submit it to request a QME panel, what happens if the worker does not submit the form within 10 days?
The claims administrator can request a QME panel by submitting form 105 and designate the specialty of the QME.
659
Why is it important which party formally submits the request for a QME panel using form 105?
The party submitting the form (form 105) to request a QME panel gets to choose the specialty of the QME.
660
After a QME panel is issued, how many days does an unrepresented injured worker have to choose a physician from the panel, schedule the QME evaluation, and notify the claims administrator of their selection and appointment?
10 days.
661
What three actions must an unrepresented injured worker complete within 10 days of receiving a QME panel?
Select one of the 3 physicians from the panel.Make an appointment with the physician for the examination/evaluation.Inform the claims administrator of the name of the physician and the date/time of the appointment.
662
What are the consequences if the Division of Workers’ Compensation (DWC) does not generate a QME panel for an unrepresented injured worker?
The unrepresented injured worker can obtain an evaluation from any QME within a reasonable geographical area.
663
What happens if an unrepresented injured worker does not notify the claims administrator about their selected physician from the QME panel within 10 days of receiving the panel?
The claims administrator may select the QME to perform the evaluation.
664
What are the consequences if an unrepresented injured worker fails to inform the claims administrator of their scheduled appointment date?
The claims administrator may arrange the QME appointment.
665
If an unrepresented employee undergoes a comprehensive medical-legal evaluation under Labor Code section 4062.1 (a) and later gains legal representation, are they entitled to an additional evaluation?
No. He or she shall not be entitled to an additional QME evaluation.
666
How is a 'represented injured worker' defined?
An injured worker who has retained an attorney.
667
From what date are panel QME evaluations available to represented workers for disputes related to an injury or a claimed injury?
January 1, 2005.
668
Under what conditions can represented workers resolve a dispute by agreeing to use an Agreed Medical Evaluator (AME)?
At any time.
669
What must occur for represented workers before they can file form 106 to request a panel of QMEs?
First, a “request for a QME” notification must be served on the opposing party to alert the opposing party. Filing form 106 is the second step to generate a panel of 3 QMEs.
670
After a request for a QME is served to the opposing party, which party in a represented worker's dispute is allowed to submit and file form 106 to request a panel of QMEs?
Either party can submit the form (form 106) to request a panel of QMEs.
671
If party A mails a request for a QME to resolve a dispute with party B, how many days must party A wait before filing form 106 to request a panel of QMEs?
10 days.
672
Once the Medical Director assigns a QME panel for represented workers, what actions can each party take?
A QME panel has 3 physicians. Each party can “strike” one physician from the list. The remaining QME shall serve as the medical evaluator.
673
How many days do the injured worker and their party have to remove a QME from the panel of three QMEs created by the DWC?
10 days.
674
How many days does the employer and their party have to eliminate a QME from the list of three QMEs provided by the DWC?
10 days.
675
What occurs if a party does not remove a physician within 10 days after a QME panel is assigned for represented workers?
The opposing party may exercise the right to strike a second physician.
676
If a represented employee has undergone a comprehensive medical-legal evaluation and later becomes unrepresented, are they eligible for another evaluation?
No.
677
Is it possible for represented workers to request a QME if the parties have already agreed to refer the case to an AME or have already submitted it to one?
No.
678
Once a QME panel is issued and a QME is selected, how many days does the chosen QME have to schedule an appointment to see the employee after receiving a request?
60 days.
679
Apart from the specialty, what factors influence which QME physicians are randomly selected for a QME panel?
The proximity of the worker’s home address with the QME’s office address.
680
Under what circumstances can a QME appointment be scheduled more than 60 days after the request date?
An appointment may be scheduled beyond 60 days of a request for an appointment if the party who has the right to schedule an appointment is willing to accept an appointment up to 90 days from the date of the request.
681
After an appointment is scheduled, what document is the QME required to submit?
The QME must submit the QME Appointment Notification form (Form 110).
682
After an appointment is confirmed, within how many business days must the QME submit the QME Appointment Notification form (Form 110)?
5 business days.
683
Who should receive the QME Appointment Notification form (Form 110) once it is completed?
The employee, the employee’s representative (if there is one), the employer or the claims administrator, and the latter’s representative.
684
What is the purpose of the QME Appointment Notification form?
The appointment notification form serves as the notice of an appointment and is also the notice for sending medical records and other information to the QME in connection with the examination.
685
What are the consequences if a QME does not submit the QME Appointment Notification form?
The failure is a cause for the issuance of a replacement QME panel (the selected QME loses the case gets replaced).
686
Is information about an interpreter included in the QME Appointment Notification form?
The QME Appointment Notification form shall state whether a state-certified interpreter is required and specify the language that is necessary.
687
If a QME cancels a scheduled appointment and verbally notifies the injured worker, what action must the QME take next?
A verbal cancellation / telephone call must be followed by a written confirmation to both parties.
688
Who is in charge of organizing and covering the costs of the interpreter for a QME evaluation?
The employer / defense party.
689
How is the term 'medical-legal cost' defined?
Specified services incurred to prove or disprove a contested case.
690
How many days before the appointment can the QME evaluator or any party cancel the appointment?
6 business days prior to the appointment date.
691
What steps must an evaluator, either QME or AME, follow when canceling a scheduled evaluation?
The evaluator must advise the parties in writing the reason for the cancellation. The evaluator must reschedule the appointment to a date within 30 calendar days of the date of cancellation (the rescheduled appointment date may not be more than 60 calendar days from the date of the initial request for an appointment, unless the parties agree in writing to accept the date beyond the 60 day limit).
692
If a QME cancels a scheduled evaluation, within how many calendar days must the appointment be rescheduled?
30 calendar days.
693
What is the required procedure when a party or their attorney cancels a QME evaluation appointment?
The cancellation can be made verbally to the QME physician and then must be followed by a written confirmation letter that is faxed or mailed to the QME physician within 24 hours of the verbal cancellation.
694
Is an injured worker responsible for missed appointments when a QME evaluation is canceled for a valid reason?
No.
695
Which authority is responsible for resolving disputes over whether a QME evaluation appointment cancellation made fewer than six days before the appointment was justified?
The Worker’s Compensation Appeals Board (W.C.A.B.).
696
Who is responsible for taking disciplinary action against a QME for violations related to appointment cancellations?
The Administrative Director.
697
Is an evaluator permitted to cancel an appointment due to not receiving the necessary medical records?
No, unless the evaluation is by a psychiatrist or psychologist under certain stipulations.
698
Can an evaluator choose to schedule or not schedule an appointment depending on whether the employee has legal representation?
No, the evaluator must schedule appointments without regard to whether or not an employee is represented.
699
How should communications between the parties and a QME be managed before the examination takes place?
All communications prior to an examination by the parties with a QME must be in writing and served on the QME at the same time as the opposing party.
700
Who is responsible for providing the QME with all records created or maintained by the employee’s treating physician(s)?
Any party.
701
Who may submit other medical records, such as prior treatment information relevant to the medical issue in dispute, to the QME?
Any party.
702
Which party may provide non-medical records, including films and videotapes relevant to the determination of medical issues in dispute, to the QME?
Any party.
703
Should a QME rely on the accuracy of the information contained in the medical records they receive?
Yes.
704
If a letter is sent to the QME before an evaluation, indicating that compensability is the issue in dispute, which party is responsible for providing this information to the QME?
Any party.
705
How many days in advance must a party share information with the opposing party before providing it to the QME?
20 days.
706
Once party B receives non-medical records from party A, how many days do they have to object and prevent those records from being sent to the QME?
10 days.
707
Is it permissible to send a QME any medical/legal report that has been rejected as untimely by a party?
In no event should the QME be sent this information.
708
Can a QME receive an evaluation or consulting report that has been removed or deemed inadmissible by a WCAB administrative law judge?
In no event should the QME be sent this information.
709
Is it allowable for a QME to receive any medical report, record, or other material that has been deemed inadmissible by a WCAB administrative law judge or found inadequate as a matter of law?
In no event should the QME be sent this information.
710
What actions can the QME take if a party does not provide relevant medical records deemed necessary for a comprehensive medical-legal evaluation?
The evaluator may contact the treating physician or other health care providers to obtain such record(s).
711
What steps should the evaluator take if a party fails to supply necessary medical records within 10 days after the evaluation date, and the evaluator cannot obtain the records?
The evaluator shall note in the report that the records were not received within 10 days after the date of the evaluation. The evaluator shall complete and serve the report within 30 days of the evaluation to comply with the usual deadline.
712
When may the QME submit a supplemental evaluation if they initially filed a report without the necessary records, which were later provided?
Upon request by either party or the Worker’s Compensation Appeals Board (WCAB).
713
When parties choose an AME to resolve a dispute, who determines what information will be provided to the AME?
Both parties must agree on the information that is sent to the AME.
714
If the history gathered by the QME from the injured worker differs from the medical records, how should the QME address this in the report?
The QME should issue opinions based on both forms of the history and then let a WCAB (Workers’ Compensation Appeals Board) judge decide the correct form of the history.
715
True or false: A QME should not gather information about how the injured worker commutes, their lost wages, or their family members’ work histories. Instead, the QME should focus on collecting details about the events immediately following the work injury.
True.
716
How is 'ex parte communication' defined?
Any communication, written or oral, by one party, or a party’s representative, with the QME outside the presence of the opposing party.
717
Is ex parte communication allowed?
Ex parte communication is forbidden in connection with the QME.
718
Why is ex parte communication prohibited?
To avoid possible covert influence by one party, or the suggestion of covert influence by one party, which would prejudice the impartial, neutral QME.
719
Does the ban on ex parte communication apply to both spoken and written interactions by the employee during the evaluation or when requested by the QME in connection with the evaluation?
No. Oral and written communications between the injured worker and the QME are allowed. Filling out written forms requested by the QME is allowed. A history collected in connection with the examination is allowed.
720
What recourse does the aggrieved party have if a party illegally communicates with the QME or if the QME communicates improperly with one of the parties?
The aggrieved party may elect to terminate the medical evaluation and seek a new QME. Or, the aggrieved party may elect to proceed with the QME evaluation.
721
In a medical-legal report, what three elements should a QME include to demonstrate that no ex parte communication occurred?
All information used in forming opinions.All information received from the parties.All information reviewed while preparing the report.
722
Is a QME allowed to contact and consult with the injured worker’s treating physician if the necessary medical records have not yet been received?
Yes, this is allowed. Even if the medical records are received, this is allowed. The QME must note the name of the treating physician and note any new or additional information received.
723
Can a party communicate directly with the QME for administrative purposes such as scheduling, verifying whether medical records were sent, or addressing missed appointments (non-substantial issues)?
No, a party is never allowed to privately communicate with the QME. All communications by a party with the QME shall be in writing and sent simultaneously to the opposing party when sent to the QME.
724
What consequences face a party that engages in prohibited ex parte communication?
The party shall be subject to being charged with contempt before the WCAB (Workers’ Compensation Appeals Board) and shall be liable for the costs incurred by the wronged party as a result of the prohibited communication.
725
Is it legally permissible for a QME to discuss administrative matters such as confirming appointments or verifying medical record submissions with the attorneys, insurance adjuster, or injured worker?
No. Absolutely no ex-parte is allowed for a QME. The Court of Appeal took a strict approach to ex parte communication stating that even for procedural matters like setting appointment dates, ex parte communications is prohibited for a QME. All communications by a party with the QME shall be in writing and sent simultaneously to the opposing party when sent to the QME.
726
Is it permissible for an AME to communicate with the attorneys, insurance adjuster, or injured worker regarding administrative issues such as confirming appointments or verifying the submission of medical records?
Yes. Labor Code section 4062.3(f) allows oral or written communications with an AME physician or the physician’s staff relative to non substantive matters such as the scheduling of appointments, missed appointments, the furnishing of records and reports, and the availability of the report.
727
Is it legal for a QME to contact the injured worker’s primary treating provider (PTP) for additional information about the worker?
Yes, the QME can reach out however, the QME must disclose the contact and the nature of information received in the QME report.
728
Under what circumstances is ex parte communication allowed?
Never.
729
Can an evaluator request or accept compensation or anything of value from any source that could create a conflict of interest with their duties?
No.
730
Under what conditions does a conflict of interest arise?
A conflict of interest exists when an evaluator has a connection of some sort—personal, financial, or otherwise—with any of the parties involved in a dispute, a connection which may interfere with an objective evaluation.
731
When is a QME allowed to disqualify themselves due to a conflict of interest?
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.
732
What actions should a QME take when they discover a conflict of interest?
Disclose the nature of the conflict in writing to the parties within 5 business days of becoming aware of the conflict.
733
What occurs when a conflict of interest is disclosed in the case of an unrepresented injured worker?
The parties are required to obtain a new QME.
734
If a QME selected from a panel realizes they have previously treated the injured worker, under what circumstances can they continue with the evaluation?
Never. A physician can never serve as QME for a case that they previously treated the injured worker.
735
In represented cases, what choices do the parties have when a conflict of interest is revealed?
The parties have the option of waiving the evaluator’s conflict of interest or, if they do not agree to waive the conflict, then to replace the evaluator’s name on the panel or request a new panel.
736
Who resolves disputes regarding whether a conflict of interest could compromise the integrity and impartiality of the evaluation?
A Workers’ Compensation Appeals Board (WCAB) administrative law judge.
737
If a QME needs an MRI to be completed before issuing an impairment rating and wants to refer the injured worker to an MRI facility owned by their brother, what actions must the QME take?
The QME must file a Financial Conflict of Interest form with the Administrative Director before sending the referral.
738
What is the highest market value of gifts an evaluator can receive annually from a single source involved in California Workers’ Compensation?
$360.
739
What four things is a QME required to disclose to the injured worker during the evaluation?
That the injured worker may ask questions about any matter concerning the evaluation process.That the injured worker may discontinue the evaluation based on good cause such as discrimination, abusive or rude behavior, and instances where the evaluator request the worker to submit to an unnecessary exam or procedure.When required, the evaluator disclose probationary status and explain the circumstances.That the QME evaluation is for assessment and not treatment.
740
If the injured worker chooses not to ask questions regarding the evaluation process and does not raise objections during the exam, can they still object to the evaluation based on good cause?
No.
741
List three 'good cause' reasons that allow an injured worker to terminate a QME evaluation after it has started.
Discriminatory conduct towards the worker based on race, sex, religion, sexual preference.Abusive, hostile, or rude behavior demonstrating bias.Unnecessary examinations.
742
If an injured worker ends an examination citing good cause (section 40), and a WCAB judge later finds that no good cause existed, who is responsible for covering the evaluation costs?
The cost of the evaluation will be deducted from the injured worker’s award.
743
If a QME has someone, 'Sam,' who reviews and summarizes the medical records for a case, what are the QME’s obligations?
The QME must review Sam’s work (compare the summary with the raw medical records) and disclose that this activity assisted in production of the report. Additionally, the QME is solely responsible for interpreting the data. The QME can only bill for the time spent personally reviewing records.
744
Who can seek assistance from the Information and Assistance Unit of the Division of Workers’ Compensation (DWC)?
Unrepresented injured workers, represented injured workers, employers, attorneys, QMEs, etc.
745
What can an injured worker request to review during their QME evaluation?
The QME’s state medical license, the QME’s certificate to perform QMEs at that location, and the QME’s curriculum vitae.
746
Which party is responsible for covering the costs of medical reports generated from an exam that was terminated for good cause?
Neither party.
747
What is a QME’s ethical responsibility concerning the injured worker’s wait time on the day of the evaluation?
Applicants should not be made to wait for longer than 1 hour. If so, then the worker can leave and request a replacement QME panel.
748
What is a QME’s ethical obligation concerning the date of a report?
The report should be dated when it is completed.
749
What ethical responsibility does a QME have regarding the opinions expressed in their report?
The QME must opine only on areas which the QME is an expert.
750
What are a QME’s ethical obligations concerning appointment cancellations?
There should be no cancellations within 6 business days of an evaluation unless there is good cause. If a cancellation does occur by the QME, then a new appointment should be offered that is within 30 calendar days.
751
What conditions must a “Physician’s office” meet to conduct QMEs and AMEs?
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.
752
For how many days must a QME maintain a physician’s office once it is listed by the DWC medical unit as available for medical-legal evaluations?
180 days.
753
What ethical responsibility does a QME have regarding the cleanliness and professional appearance of their office?
The office must be clean and professional.
754
Where should Qualified Medical Evaluations take place?
In an office location that has been approved for QME examinations by the California Division of Workers’ Compensation (DWC).
755
Can the initial appointment location be changed, except in rare circumstances?
No. The initial appointment location can never be moved. (Remember, the physicians who were generated on a QME panel are based on proximity to the injured worker).
756
Are subsequent QME evaluations, including re-evaluations and follow-up visits, allowed to take place at different locations?
Yes, but only at locations that the QME has listed on the official DWC website.
757
What ethical responsibilities does a QME have in addressing issues raised in cover letters?
The pertinent issues should be addressed.
758
Is an evaluator obligated to begin or continue an evaluation with an injured worker (or their representative) if the worker uses abusive language, disrupts the office, is intoxicated, or is under the influence of medications impairing their ability to participate in the evaluation?
No. The evaluator shall state the facts supporting the termination of the evaluation process.
759
Even though questioning the integrity of an injured worker is inappropriate, should the QME present and clarify inconsistencies in the worker’s history in the QME report?
Yes.
760
How is face-to-face time defined?
Face-to-face time means only that time the QME is present with an injured worker during an evaluation.
761
What is the required minimum face-to-face time for neuromusculoskeletal evaluations?
20 minutes
762
What is the minimum amount of face-to-face time required for cardiovascular evaluations?
30 minutes
763
How much face-to-face time is required as a minimum for pulmonary evaluations?
30 minutes
764
What is the required minimum face-to-face time for psychiatric evaluations?
60 minutes
765
What is the minimum face-to-face time required for evaluations that are not neuromusculoskeletal, cardiovascular, pulmonary, or psychiatric?
30 minutes.
766
Where are the evaluation protocols located for injuries occurring on or after January 1, 2005?
In the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition (AMA Guides).
767
True or false: California has set protocols for evaluating injured workers in fields such as immunology, neuromusculoskeletal, cardiac, psychiatry, and pulmonary.
True.
768
When a QME conducts an evaluation with the assistance of an interpreter, what is classified as face-to-face time for billing purposes?
Face-to-face time means only that time the QME is present with an injured worker during the evaluation.
769
True or false: When a QME gathers history and conducts a physical exam, it is counted as face-to-face time, but time spent by the injured worker with a historian, completing paperwork, and performing diagnostic tests is not considered face-to-face time.
True.
770
If an injured worker wants to record the QME evaluation, is the QME required to permit this?
Yes, this is allowed.
771
If a QME wants the injured worker to undergo a diagnostic test to aid in the QME report (e.g., a knee x-ray to assess arthritis severity), is this permitted?
Yes, this is allowed but the QME must first get authorization from the Insurance (claims) Adjuster before writing an order for the diagnostic test.
772
Must the date and the street address of the completed examination be included in the body of the comprehensive medical-legal report?
Yes.
773
If the evaluator signs the report on a different date than when the examination was completed, what action must they take?
Sign the report on the date the report was completed. Enter the date the report was completed near the signature on the report.
774
Is the evaluator required to address all disputed medical issues stemming from injuries reported on claim forms before the employee’s QME evaluation appointment?
Yes, as long as the issues are within the evaluator scope of practice in areas of clinical competence.
775
What steps should the evaluator take when faced with disputed issues that fall outside their area of expertise?
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.
776
How is “preponderance of the evidence” defined?
Preponderance of the evidence means, “such evidence as, when weighed with that opposed to it, has more convincing force and the greater probability of truth. When weighing the evidence, the test is not the relative number of witnesses, but the relative convincing force of the evidence.”
777
How can “preponderance of the evidence” be explained in simpler terms?
The party must prove that its position is more likely than not to be correct.
778
Who bears the burden of proof to demonstrate by a “preponderance of evidence” that an injury was work-related?
The injured worker.
779
Who carries the burden of proof to establish that an injury was intentionally self-inflicted?
The employer.
780
Who has the burden of proof in matters of apportionment regarding the cause of permanent impairment or disability?
The employer.
781
According to Labor Code section 4628, what declaration must be part of the QME’s report?
“I declare, under the penalty of perjury, that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as to information that I have indicated I received from others. As to that information, I declare, under the penalty of perjury, that the information accurately describes the information provided to me and, except as noted herein, that I believe it to be true.”
782
Once a QME report is completed, what steps should the QME take if new evidence or additional research leads to a change in their opinions?
The QME is permitted to change their mind even after a QME report is served. The QME would issue a Supplemental report explaining the new opinions.
783
Can a QME bill for time spent reviewing the AMA guides, ACOEM treatment guidelines, MTUS treatment guidelines, Labor Codes, or California Code of Regulations under the “research” billing category?
No.
784
How is the initial evaluation performed by a QME referred to?
A comprehensive medical-legal evaluation.
785
Who performs a subsequent QME evaluation when a clinical issue arises within the competency of the original QME-physician and that physician remains available?
The parties must return to the QME-physician who originally provided a medical opinion in the case.
786
Typically, how much more is an evaluator paid if chosen as an AME for a case?
Evaluating a case as an AME pays 25% more for that single case (compared to evaluating the case as a QME).
787
If an injured worker receives a medical evaluation from a doctor who is not their PTP, QME, or AME and submits the report to the QME, what action must the QME take?
While this report is inadmissible, the QME must issue a report commenting on the self-procured report.
788
When is a QME required to inform the DWC Medical Director of a future period of unavailability?
When the length of an unavailability period is 14 days to 90 days.
789
If a QME intends to be unavailable for 14 to 90 days, when must they notify the DWC Medical Director?
At least 30 days before the period of unavailability begins.
790
What occurs if a QME does not inform the DWC Medical Director at least 30 days before their planned period of unavailability?
The period of unavailability may begin 30 days from the date the DWC Medical Director learns of the unavailability.
791
What information must a QME provide to the DWC Medical Director when requesting unavailable status?
A list of any and all comprehensive medical–legal evaluation examinations already scheduled during the time requested for unavailable status and shall indicate whether each such examination is rescheduled or if the QME plans to complete the examination and report while in unavailable status.
792
What is the maximum number of days a QME can be unavailable during a calendar year?
90 days.
793
What are some examples of good cause for a QME to be unavailable?
Death or serious illness of an immediate family member, a sabbatical.
794
What should the parties do if a follow-up evaluation is needed that exceeds the original QME-physician's scope of practice or limitations?
The parties may request the issuance of an additional QME-physician by agreeing in writing on the need for an additional QME panel and on the specialty of the additional QME.
795
What is the deadline for submitting a comprehensive medical-legal evaluation report?
The report shall not be submitted in excess of 30 calendar days after the evaluation.
796
From the date of the evaluation, how many days does a QME have to submit their report?
30 days.
797
What are the consequences if a QME fails to timely serve a completed medical-legal evaluation report?
Either party may request a QME replacement.
798
What are some reasons for issuing a replacement QME panel?
The chosen QME cannot schedule an appointment within 60 days.The chosen QME’s report was untimely and the party objected after being served with the report.The evaluator who previously reported in the case is no longer available.The specialty chosen was inappropriate.1 or more of the QME’s on the panel does not practice in the specialty requested.The injured worker has changed his or her residence address since the QME panel was issued and prior to date of the initial evaluation of the injured worker.
799
What is the deadline for submitting a supplemental report?
The report shall be submitted and serve no more than 60 days from the date of request to the QME physician by a party.
800
Does a Supplemental Medical-Legal Report require examining the injured worker?
No.
801
Does a Supplemental Medical-Legal Report include face-to-face interaction with the injured worker?
No.
802
Is it possible for a supplemental medical-legal report to include a narrative discussing new records, test results, or videos?
Yes. The report shall be submitted and served no more than 60 days from the date of request to the QME physician by a party.
803
Is a face-to-face examination of the injured worker required in a QME re-evaluation?
Yes.
804
Does a QME re-evaluation involve creating a narrative report and reviewing new diagnostic tests, medical records, and/or sub-rosa videos?
Yes.
805
Within how many days after the evaluation must a QME re-evaluation report be served?
30 days.
806
Who is responsible for covering the payment for an evaluation if the report is submitted late?
Neither the employee nor the employer shall have any liability for payment for the medical evaluation and report which was not completed within time frame.
807
If a report is submitted late but the parties wish to accept it, what steps must be taken?
The employee and the employer must waive their right to a new evaluation and elect to accept the original (late) report.
808
Who is permitted to object to a QME’s report if it is submitted late?
The employer, the insurance (claims) adjuster, either party’s attorney, and/or the injured worker.
809
How long does a QME have to respond when an unrepresented injured worker files a Request for Factual Correction of an Unrepresented Panel QME Report?
The panel QME shall have 10 days after service of the request to review the corrections requested in the form and determine if actual corrections are necessary to ensure the factual accuracy of the report.
810
What are five examples that can be considered 'good cause' for a QME to request an extension to file a report?
Death in the QME’s family.Community disasters that disrupt the QME’s business.Medical emergency for the QME or the QME’s family.Natural disasters.Damage to the QME’s office.
811
How much additional time is a QME granted to submit a report when an extension for good cause is approved?
15 days. Note that the request for an extension must be filed within the usual report deadlines.
812
Can a QME request an extension if they are waiting for test results or medical records, and if so, how long is the extension for?
Yes, for 30 days. Note that the request for an extension must be filed within the usual report deadlines.
813
What is the maximum time limit allowed for extending an evaluation date?
The evaluator may request an extension from the Medical Director, not to exceed an additional 30 days.
814
After receiving notification of a deposition, how long does a QME have to schedule it?
Depositions must be scheduled within 120 days of the notice.
815
Who receives a completed report in the case of a represented injured worker?
The evaluator shall serve each report on the injured worker, their attorney, and on the claims administrator (if there is no claims administrator, then on the employer).
816
What must be sent after an evaluation and to whom in the case of an unrepresented injured worker?
The QME shall serve a completed QME Findings Summary Form as well as the report to the injured worker and the claims administrator (if there is no claims administrator, then on the employer).
817
How is the term 'D.E.U.' defined?
Disability Evaluation Unit.
818
What are the responsibilities of the D.E.U.?
The DEU office issues summary disability ratings. “Raters” within the DEU convert permanent impairment ratings into summary disability ratings.
819
If a QME's report for an unrepresented injured worker addresses permanent impairment, disability, or apportionment, to whom else must the report be sent?
Besides serving the report to the unrepresented injured worker and the Insurance Adjuster (claims administrator), the evaluator shall serve the evaluation report on the Disability Evaluation Unit (D.E.U.) office.
820
For how long is a QME required to retain copies of all comprehensive medical-legal reports?
The QME should retain a copy of all reports for a period of 5 years from the date of the report.
821
Can a QME retain electronic copies of reports to meet the 5-year retention requirement?
Yes, as long as the electronic copy retained is a true and correct copy of the original.
822
How long must a QME retain billing records?
The QME should retain a copy of bills for 3 years.
823
If a worker is injured and wants to proceed with a claim, what steps should they take?
Fill out and give his employer the Division of Workers’ Compensation (DWC) “Claim Form” (DWC Form 1).
824
What actions should an employer take when a worker is injured and wishes to proceed with a claim?
Fill out the “Employer’s Report of Occupational Injury or Illness” (Form 5020).
825
What should the first occupational doctor do when treating a worker who is injured and wishes to proceed with a claim?
Fill out the “Doctor’s First Report of Occupational Injury or Illness” (Form 5021).
826
If a worker completes DWC form 1, 'Claim Form,' and submits it to their employer, how many days does the employer have to pass the form to the insurance adjuster or claims administrator?
1 working day. This is so that the injured worker can receive treatments in a timely manner.
827
After a worker submits DWC Form 1 'Claim Form' for a new injury, how long does the insurance adjuster or claims administrator have to respond?
90 days. If there is no response, then the claim is presumed to be industrial and the injured worker can have up to $10,000 in medical treatments.
828
What is the goal of medical treatment in the workers' compensation system?
To cure or relieve the effects of industrial injuries.
829
According to Labor Code 4600, what medical treatments are available to injured workers?
Medical, surgical, chiropractic, acupuncture, hospital treatment (and nursing), medicines, medical supplies, surgical supplies, crutches, orthotics, prosthetics.
830
What fee schedule is used to determine reimbursement for doctors treating injured workers?
The Official Medical Fee Schedule (OMFS).
831
How is the term 'treating physician' defined?
A physician who provides direct medical treatment to an employee which is reasonably required to cure or relieve the effects of an industrial injury.
832
What does 'primary treating physician (PTP)' mean?
This is the physician who is primarily responsible for managing the care of an employee, and who has examined the employee at least once for the purpose of rendering or prescribing treatment and has monitored the effect of the treatment thereafter.
833
How many primary treating physicians is a patient allowed to have?
1
834
When an injured worker sees a primary treating physician (PTP) for a new injury, how long does the PTP have to send the 'Doctor’s First Report of Occupational Illness or Injury' to the relevant parties?
Within 5 days of the initial examination.
835
If a primary treating physician writes a report for an injured worker and there are no disputed or contested issues, can it be classified as a medical-legal report and billed accordingly?
No, this is not a medical-legal report. This should be billed under the Official Medical Fee Schedule (O.M.F.S.) and not the medical legal fee schedule.
836
What two treatment guidelines must doctors follow when treating injured workers to ensure their treatment is not denied by Utilization Review?
Medical Treatment Utilization Schedule (MTUS).American College of Occupational and Environmental Medicine (ACOEM).
837
What method should a primary treating physician use to obtain authorization from the insurance company for a treatment ordered for an injured worker?
A Request for Authorization (R.F.A.).
838
Under Senate Bill 899 (SB899), how many visits can an injured worker have with a chiropractor, physical therapist, and occupational therapist?
A maximum of 24 with each of these.
839
Before January 1, 2005, what was the maximum number of visits allowed for chiropractic, physical therapy, and occupational therapy?
There was no limit.
840
How often must a primary treating physician report on the injured worker’s condition using form PR-2?
45 days.
841
How is the term 'released from care' defined?
This is when a primary treating physician (PTP) determines that an injured worker’s injuries have fully resolved and do not require continued treatment. The injured worker has no permanent impairments.
842
What does it signify when the injured worker’s primary treating physician (PTP) states that the worker's lumbar spine has returned to pre-injury status?
It means that the lumbar spine injury has resolved.
843
When the injured worker’s primary treating physician (PTP) declares the injury permanent and stationary (P&S) and writes a permanent and stationary report (PR-4), does this imply that there is impairment or disability?
Yes, at least some permanent impairment/disability exits. Otherwise, the doctor could have discharged the worker as cured/ released from care.
844
Under what condition is a primary treating physician’s (PTP) permanent and stationary report (PR-4) classified as a medical-legal report?
When the claim is contested or disputed.
845
How is 'future medical care' defined?
Future medical benefits/ treatments are an injured worker’s right to receive ongoing medical treatment after a workers’ compensation injury claim has been settled/closed. The treatments should relieve or cure effects from the injury sustained at work.
846
When is an employer or defense party required to provide an interpreter for an injured worker who does not speak or understand English?
For treatment visits, medical-legal examinations, appeals board hearings, and depositions.
847
What are the penalties and fees if a California employer does not have workers' compensation insurance?
1 year imprisonment, fines up to $10,000, and state penalties up to $100,000.
848
How much is an employer liable if they do not have workers' compensation insurance and an employee is injured on the job?
The employer is responsible for all medical bills related to the injury. The injured worker can also file a civil lawsuit against the employer.
849
Who is responsible for paying disability and temporary disability benefits to the injured worker if the employer lacks workers' compensation insurance?
The Uninsured Employers’ Benefit Trust Fund (U.E.B.T.F.) pays benefits to injured workers if their employer was uninsured.
850
What does M.P.N. stand for, and who is responsible for selecting the doctors included in the M.P.N.?
Medical Provider Network (M.P.N.).Insurance companies choose which doctors are included within the MPN to treat injured workers. Each insurance company has its own MPN.
851
Who decides which doctors are listed on the M.P.N.?
Insurance companies choose which doctors are included within the MPN to treat injured workers. Each insurance company has its own MPN.
852
How much time does an employer have to grant access to a physician within the MPN after an injury is claimed?
24 hours.
853
If an injured worker being treated by a physician in the MPN requests a change of physician within the network, how quickly must this request be fulfilled?
Within 5 days of the request.
854
What occurs if an employer fails to provide an injured worker with a physician within the MPN within 30 days after the injury was claimed?
The injured worker may select any physician of their choosing.
855
What types of physicians are eligible to conduct Independent Medical Review (IMR) determinations regarding treatments for injured workers?
M.D.’s, D.O.’s, and D.P.M.’s.
856
How is the term 'secondary physician' defined?
This is any other physician besides the injured worker’s primary treating physician (PTP) who treats the injured worker.
857
Can medical records from a secondary treating physician be submitted as evidence at the Workers' Compensation Appeals Board (WCAB)?
No. Only reports from QMEs, AMEs, and PTPs are admissible. An exception does exist: if the PTP adopts the secondary physician’s report, then the report is admissible.
858
Under what circumstances can an employee change their pre-designated personal physician in the event of an industrial injury?
At any time.
859
What steps must an employee take to pre-designate their personal physician?
Pre-designation must be in writing, the personal physician must be an MD or DO, and the pre-designation must be provided prior to the industrial injury.
860
Who is accountable for providing the supplemental job displacement benefits voucher, also known as 'the voucher'?
The first doctor to make an injured worker Permanent and Stationary (P&S)/ determine that the injured worker has reached a point of maximal medical improvement.
861
Once an AME, QME, or Primary Treating Physician (PTP) concludes that a worker is Permanent and Stationary (P&S) or has reached maximal medical improvement, how many days does the physician have to submit the voucher?
60 days.
862
What is the value of the voucher for vocational rehabilitation benefits for injuries occurring on or after January 1, 2013?
A flat rate of $6,000.
863
What is the value of the vocational rehabilitation voucher for injuries that occurred before January 1, 2013?
A range from $1 to a maximum of $16,000.
864
What can the injured worker use the supplemental job displacement benefits voucher for?
Tools required for job training, licensing/certification/testing fees for a new job, schooling at a California public schools or other approved state providers, up to $1,000 for a computer, $500 in miscellaneous expenses, and up to $600 for a job placement agency or vocational counselor.
865
What can a QME do if they let their certification lapse by failing to pay re-certification fees, and an injured worker requests a re-evaluation?
The QME cannot do a face-to-face re-evaluation of this injured worker. However, the QME can issue a supplemental report (a supplemental report does not involve a face-to-face evaluation).
866
Is a physician allowed to bill for time spent reviewing previously reviewed medical records, their own reports and records, and for general deposition preparation?
Yes.
867
Is a physician permitted to bill for their travel time to attend a deposition?
Yes.
868
If no medical records are provided to the QME before or after the evaluation and the QME issues a report within the 30-day limit, but medical records are later received, what steps should the QME take?
Review the records and issue a supplemental report detailing the new findings and updating any opinions that the new information may have affected.
869
If no medical records are received by a QME before or after the evaluation, is the QME still required to issue a medical-legal report, and how long does the QME have to issue the report?
Yes. 30 days as per usual.
870
If no medical records are received by a QME before or after the evaluation, can the QME legally contact the injured worker's primary treating physician to obtain the records?
Yes.
871
When an injured worker does not speak English and is entitled to a certified California interpreter, what information must the QME document in the report?
The name and the certification number of the interpreter.
872
What does a -92 modifier represent when added to billing codes?
That the evaluation was performed by the primary treating physician (PTP).
873
What does a -93 modifier represent when added to billing codes?
That the evaluator had the help of a certified interpreter.
874
What does a -94 modifier represent when added to billing codes?
That the evaluation was an AME.
875
What does a -95 modifier represent when added to billing codes?
That the evaluation was an QME.
876
How is 'precipitation' defined?
Precipitation is when work exposure causes a previously asymptomatic condition or problem to manifest.
877
How is 'acceleration' defined?
Acceleration is when work exposure makes a previously asymptomatic condition or problem manifest sooner than without work. It also refers to work exposure rapidly worsening a condition.
878
Provide examples of situations in which an employer is not liable for a worker's injuries.
The employee was intoxicated or was illegally using controlled substance(s).The injury was intentionally self-inflicted.The employee committed suicide. Injuries from an altercation that the employee started. Injuries from a felony or crime.Injuries from recreational, social, and athletic activities, not related to usual work duties, unless the employer expected the employee to participate.Psychological injuries caused by being laid off/terminated/fired in good faith. These are discussed in Labor Code 3600 (LC 3600).
879
True or false: Each medical-legal report must include the following declaration, signed and dated with the county of signature, stating, 'I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as to information that I have indicated I received from others. As to that information, I declare under penalty of perjury that the information accurately describes the information provided to me and, except as noted herein, that I believe it to be true.'
True.
880
If a QME cannot complete an evaluation due to time constraints and asks the injured worker to return, how many days does the QME have to submit the report, and when does the time period start?
30 days, as per usual. The 30-day countdown starts at the first visit when the injured worker was seen.
881
Is a QME responsible for providing treatment or treatment advice to injured workers?
No. A QME evaluation is for assessment and evaluation only.
882
After ordering a diagnostic test that reveals a new diagnosis, what is the QME’s responsibility?
The QME must inform the parties of the new diagnosis and the QME can suggest other related medical assessments.
883
When a QME uses the AMA Guides and obtains an impairment rating with a decimal, what steps should the QME take?
Round to the nearest whole number.
884
True or false: Under California Workers' Compensation guidelines before 1/1/2005, 'constant' is defined as 90-100% of the time, 'frequent' as 75%, 'intermittent' as 50%, and 'occasional' as 25%.
True.
885
What is an 'agreed panel QME,' apart from a QME and an AME?
This is when a QME panel of 3 QME’s is generated and both the injured worker and the defense agree on one of the QMEs. In other words, there is no striking.
886
How is the term 'evidence-based' defined according to the DWC?
Based on medical journals included on the website www.pubmed.gov.
887
How are the 'three factors that demonstrate functional improvement' defined?
A clinically significant improvement in activities of daily living.A reduction in work restrictions as measured during the history and physical examination.A reduction in the dependency on continued medical treatment.
888
What constitutes good cause for the DWC medical director to grant permission for a second QME in a different specialty?
When the first QME says that an additional QME as needed in a different specialty.Upon the order of the Worker’s Compensation judge.The parties agree.
889
For psychological injuries that occurred on or after January 1, 2005 and are deemed permanent and stationary, what method is used to determine the extent of injury?
Global Assessment of Functioning score (GAF score).
890
What is used to assess impairment in a psychological injury claim?
Global Assessment of Function (GAF) scores.
891
What additional requirement must clinical psychologists fulfill to become psychology QMEs?
They must have at least 5 years of experience, after graduating, in treating psychological disorders.
892
If a QME is concerned that part of a report involving psychological injury may harm the injured worker's mental state, what two actions should the QME take?
Complete Form 120: “Voluntary direction for alternate service of medical-legal evaluation report on disputed injury to psyche (unrepresented employees only)” to have another doctor receive the report and explain it to the injured worker.Complete Form 121: “Declaration regarding protection of mental health record” to protect the disclosure of mental health records.
893
In psychology-related claims, what three elements must the injured worker generally prove?
That greater than 50% of the psychological injury was caused by work.The injured worker must have worked for the employer for over 6 months.The psychological injury must not be a consequence of a physical injury.
894
If a worker claims psychological injury after being threatened at gunpoint, what percentage of the psychological injury must the worker prove was work-related?
Because this is a violent act (a sudden and extraordinary event), 35% or greater is the threshold. In addition, the 6-month requirement does not apply.
895
If an employer terminates an employee for valid reasons and the employee files a claim, proving that 51% of their new psychological injury resulted from the termination, is the claim compensable?
No, because this was a “good faith personnel action.”
896
How long must a worker have been employed by an employer to be eligible to file a psychological injury claim?
6 months. The exception to this rule is if there was a sudden or extraordinary event.
897
What is the purpose of temporary disability indemnity (TDI) for a worker?
To substitute for the worker’s lost wages, in order to maintain a steady stream of income. This is also known as temporary disability benefits.
898
What are three situations in which an employer is no longer required to pay for temporary disability indemnity (TDI)?
The injured worker returns to work.The injured worker is deemed able to return to work.The injured worker’s medical condition achieves permanent and stationary status.
899
When an injured worker who typically lifts 100-pound bushels is restricted by their doctor to lifting no more than 10 pounds and the employer temporarily assigns the worker a desk job, what is this arrangement called?
Reasonable accommodation. This is also known as modified work.
900
What is it called when an injured worker's doctor restricts them from lifting more than 10 pounds and the employer has no available work, leaving the worker unable to work?
Temporary total disability (TTD).
901
For how long is an injured worker on temporary total disability entitled to receive temporary disability compensation (monetary payments) after January 1, 2005?
104 weeks (2 years).
902
What types of injuries qualify an injured worker for temporary disability benefits exceeding 104 weeks (240 weeks)?
Acute and chronic hepatitis B and C.Amputations.Severe burns.Human immunodeficiency virus (HIV).High-velocity eye injuries.Chemical burns to the eyes.Pulmonary fibrosis.Chronic lung disease.
903
Under what circumstances can an injured worker who continues to work with reasonable accommodations also receive temporary disability compensation (monetary payments)?
If the modified work pays less than 85% of the injured worker’s usual salary.
904
When an injured worker feels better and returns to work with modified duties, do temporary disability payments cease?
Yes.
905
If an injured worker’s QME concludes that the worker's injuries will not improve and have reached maximal medical improvement/permanent and stationary status, do temporary disability payments stop?
Yes.
