1
Q
Hold authority to appoint physicians as QMEs
A
Administrative Director
2
Q
3 requirements when seeking appointment as QME
A
Pass exam
12 eval writing course
Devote at least 1/3 of total practice time to direct medical tx (or serve as AME 8 times in past 12 months
3
Q
2 reasons for QME termination or suspension without a hearing
A
Licensing board pulls license
Fail to pay fees
4
Q
6 reasons for discipline post hearing
A
Violation of material statutory or administrative duty
Failure to follow medical procedures
Failure to comply with timeframes
Failure to meet licensure requirements
Failure of reports to meet minimum standards
False statements on application
5
Q
A
6
Q
3 types of disputes resolved by QME
A
Compensability of a claim
Permanent disability
“Catch all”
7
Q
Definition of injury in compensability claims
A
Injury arising out of employment
Secondary injury arising from tx of injury arising from employment
Reaction to or side effect from preventative health care provided by employer
8
Q
Specific injury
A
Occurs as a result of a single incident or exposure
9
Q
Cumulative injury
A
Results from repetitive trauma over time
10
Q
2 requirements for a condition to be an injury
A
Cause disability or
Results in the need for medical treatment
11
Q
7 injuries excluded from compensation
A
Caused by employee’s use of alcohol or illegal drugs
Intentional self-harm
Suicide
Resulting from altercations when the employee is the aggressor
Resulting from employee’s commission if a felony
Resulting from off-duty recreational activities
Psychiatric injuries claimed after notice of termination
12
Q
4 basic conditions that establish a worker’s compensation claim
A
Injury
Employment relationship
Injury arising out of employment (caused by work)
Occurred in the course of employment
13
Q
Aggravation of a pre-existing, non-industrial condition
A
Causes a temporary or permanent increase in disability
Creates a new need for medical treatment; or
Requires a change in existing course of treatment
14
Q
Symptoms which do not constitute a new injury
A
Flare-ups or recurrence of a previous industrial injury or illness not caused by the current employment
15
Q
Date of Injury - Specific injury
A
Date on which the incident or exposure occurred
16
Q
Date of Injury - Cumulative injury
A
Date the employee first suffered disability from the exposure, and either knew, or should have known that the disability was caused by present or previous employment
17
Q
Items determined by the date of injury
A
Statute of limitations for particular procedures within the worker’s compensation system
Regulations that will apply to the worker’s injury
Compensation rate for the worker’s injury
Employers who are liable for the claim
18
Q
Reasonable Medical Probability
A
Standard by which QME uses a combination of existing medical and scientific knowledge and the occupational and medical history of the worker to conclude whether the worker’s exposure contributed to the injury
19
Q
Evidentiary standard of causation/contribution
A
Preponderance of evidence (greater than 50% likely)
20
Q
5 major types of causation
A
Direct, contributing, acceleration, precipitation, aggravation
21
Q
Direct causation
A
Work exposures are directly responsible for the health outcome
22
Q
Contributing causation
A
Several factors, including work, led to the disease
23
Q
Acceleration
A
Disease process is accelerated by virtue of the work exposure. The date of onset of the disease is much sooner than would be expected without the exposure
24
Q
Precipitation
A
Work exposure precipitates the manifestation of the illness. For example, an underlying tendency or asymptomatic problem was present, but the work exposure causes it to clinically manifest
25
Aggravation
A medical condition may be present alrady, but work exposure makes it worse
26
"Taking employees as you find them"
Employer cannot avoid liability for an injury by claiming that the injury would not have happened if the worker had been in a different physical or emotional condition before the accident
27
Criteria for compensation of psychiatric injuries
Diagnosed mental disorder
Dx causes disability or need for medical treatment
Employee can demonstrate that the events of employment were the predominant cause of the injury (greater than 50%)
28
Limits for claims of psychiatric injury
- Actual events of employment were the predominant cause among all combined of psychiatric injury (except if the injury is derivative of an underlying physical injury)
- If the injury results from a violent act (or direct exposure to a violent act), events of employment must attribute at least 30% of the causation
- Employee was employed by employer greater or equal to six months (not continuously)
- Injury was not substantially (greater or equal to 35%) cause by good faith personnel actions
- Claim cannot be filed after notification of termination
29
Perception is not disability
Disability is not based on how much stress should have been felt, but rather how much stress the worker is feeling
30
Proximate cause
Causal connection between injury and work
Employment needs only be a contributing cause
31
Criteria for compensability of psychiatric claims made after notice of termination
- Injury was the result of sudden and extraordinary events of employment
- Employer had notice of the injury before the notice of termination
- Medical records existing before the notice of termination contained evidence of tx of the injury
- A decisional authority (like a judge) found that there was sexual or racial harrassment
- There is evidence that the DOI is subsequent to the date of notice of termination, but before the effective date of the termination
32
Who has the first right to request a QME exam to determine compensability?
Injuired worker, regarldess of representation
33
LOOK UP ITEM 36
34
How is a permanent disability rating determined
- Disability evaluation
- Rating schedule that correlates impairment with disability
35
Who/how is an impairment rating determined
By a physician, using the AMA guides
36
Who is responsible for assigning the permanent disability rating
A rating specialist with the DEU of the DWC (not physicians)
37
Who has the right to invoke an evaluation of permanent disability
Injured worker or claims administrator
38
What is a trigger for a permanent disability dispute
Termination of temporary disability by treating physician (via report)
39
What causes termination of temporary disability
Finding of permanent and stationary or maximum medical improvement by primary treating physician
40
What is the only admissible report before a WCJ on the issue of permanent disability
a QME report prepared by treating physician
41
What is apportionment
- An approximate percentage of permanent disability caused by a work-related injury as well as other factors (i.e. non-work)
- Only applies to permanent disability
42
Regions of the body
Hearing, vision, mental, spine, upper and lower extermeties, head, face, CV system, respiratory system, all other systems
43
Criteria for presumptive 100% awards
- Loss of both eyes or sight in both eyes
- Loss of both hands or use of both hands
- Injury resulting in particular total paralysis
- Injury to the brain, resulting in incurable mental incapacity or insanity
44
What is a trigger for the comprehensive medical evaluation for permanent disability by an AME/QME
Injured worker or employer wishes to context training physician's evaluation
45
Definition of impairment (per AMA guides)
- Loss, loss of use, or derangement of any body part, organ system, or organ function
- Change from a normal/pre-existing state
46
Definition of disability (per AMA guides)
Alteration of an individual's capacity to meet personal, social, or occupational demands or stationary or regulatory requirements because of an impairment
47
Who is responsible for assigning QME panels
DWC Executive Medical Director
48
Time frame in which either party in represented cases may object to a medical determination by the treating physician
20 days, in writing
49
Time frame in which either party in unrepresented cases may object to a medication determination by the treating physician
30 days, in writing
50
Time limit for unrepresented injured worker to submit request for a QME panel after receiving form from their employer
10 days
51
Time frame after which unrepresented worker as the right to obtain an evaluation from any QME within a reasonable geographical area
After 20 days, if the request for a QME panel is not issued
52
Time frame in which an injured worker is required to select a physician from the QME panel, make an appointment for the exam, and inform the claims administrator of the selection and appointment
Within 10 days after the panel is issued
53
Rights of the claim administrator in selecting QME and arranging the appointment
If the injured worker does not inform the claims administrator of the seletiono or the date of the appointment
54
Time frame in represented cases during which each party may strike one name from the QME panel
10 days after assignment of the panel
55
Time frame in which the selected QME must schedule an appointment to see the injured worker
Within 60 days of the request for an appointment (up to 90 days)
56
Time frame to submite the QME appointment notification form
Within 5 business days of making the appointment
57
Parties receiving service of the QME appointment notification form
- Employee (and representative/AA)
- Employer/claims administrator (and representative/DA)
57
Trigger to send medical records and other information to QME
Receipt of the QME appointment notification form (ANF)
58
Causes for issuance of a replacement panel
- Failure to serve the QME appointment notification form
- Disclosure of COI by the evaluate after appointment has been made
- Necessity for a subsequent examination by a QME in a different specialty (due to limitations in socpe of practice or clinical competency)
- QME doesn't practice in the requested specialty
- QME cannot schedule an appointment wihin 60 days of the initial request for the appointment
- Inured worker changes address since the initial request for a panel but before the initial appointment
- Two or more members of the QME panel are from the same group practice
- QME is unavailable
- QME who previously reported on the case is unavailable
- QME currently, or has been, the treating physician of the worker for the injury currently under dispute
- Untimely filing of report by QME
- QME doesn't cancel appointment in timely manner
- QME panel was issued more than 24 months prior to the request for the replacement panel and none of the QMEs have examined the worker
- Qualified and competent QME refuses to provide an eval or written statement explaining why they are not qualified or competent to address one or more issues in dispute in the case
- Administrative director orders on an additional QME evaluation
59
Who is responsible for arranging and paying for an interpreter for the QME exam
Employer
60
Information which may be provided to the QME by any party
- All records prepared/maintained by treating physicians
- Other medical records relevant tot he determination of medical issue and dispute
- Letter outlining medical determination of the primary treating physician or the compensability issue request ot address the evaluation
- If concerning a dispute over a UR decision, a copy of the treating physician's report and the claim administrator's decision to approve, delay, deny or modify the disputed treatment
- Non-medical records relevant to determination of the medical issues in dispute
61
Time frame for services of info on an opposing party that a party proposes to provide to the selected QME
20 days before the info is provided to the evaluator
62
Info which should never be sent to the selected QME
- Any medical/legal report rejected by a party as untimely
- Evaluation written by a physician other than the treating physician that addresses permanent impairment, permanent disability, or apportionment (unless ruled admissible by the WCALJ)
63
Ex-parte contact
Any communication by one party with the evaluator outside of the presence of the opposing party
64
Conflict of interest
Evaluator may not request or accept any compensation or thing of value from any source that does or could create a conflict with their duties as an evaluator
65
Persons/entities with whom a QME may hav ea disqualifying COI
- Injured worker or their attorney
- Employer or their attorney
- Claims administrator or their attorney
- Primary/secondary treating physician, if treatment by physician is being disputed
- You are physician reviewer or expert reviewer or UR organization if decision is being disputed
- Surgical center if surgery is being disputed
- Purveyor of medical goods/services if goods/services are being disputed
66
Disqualifying COIs
- Familial relationship, including cohabitation
- Significant financial interest
- Professional affiliation in same medical group/business affiliation
- Any other relationship/interest which would entertain doubt that evaluator would be able to act with integrity and impartiality
67
Timeframe for unevaluated to disclose COI
Within 5 business days of becoming aware of the conflict and in writing
68
Options of represented workers after disclosure of COI by evaluator
- Wave the COI
- Replace evaluators name on the panel (if COI discovered before any names stricken)
- Reqeust a new panel (if COI discovered after appointment made)
69
Decider of disputes about whether a COI may affect the integrity and impartiality of the evaluation or supplemental reports
WCALJ assigned to the case
70
Required exam disclosures
- Injured worker may ask questions about any matter concerning the eval process
- Injured worker may discontinue the eval based on good cause
- Disclosure of probationary status, if required as a condition of probation
71
Good cause for discontinuing the eval by an injured worker
- Discriminatory conduct
- Abusive, hostile, or rude behavior
- Request that worker submit to an unnecessary exam or procedure
72
Good cause for discontinuing an eval by a QME
- Worker/representative uses abusive language
- Worker/representative attempts to disrupt the office operations in any way
- Worker is drunk or under the influence of meds which impairs their ability to participate
73
Face-to-Face time
Only time that counts is what is spent with the worker (taking history, performing exam, etc)
74
Minimum face-to-face requirements for uncomplicated evals
- Neuromusculoskeletal: 20 minutes
- Psych: 60 minutes
- All others: 30 minutes
75
Required contents of reports
- Date of exam
- Street address where exam was performed
- All contested medical issues arising from all injuries reported on one or more claim forms prior to the appointment that are within the scope of practice and areas of clinical competence
- Disputed issues beyond the evaluator's expertise
76
Parties who may participate in the non-clerical preparation of the report
- Evaluating physician
77
Unallowed referrals
- Outside referrals in which the physician or their family has a financial interest
- Cross referral rearrangement or other schems whose primary purpose is to ensure referrals
- Any kind of compensation or inducement for referred evals and consults
78
Exceptions to unallowed referrals
- Physician discloses financial interest and referred services to patient
- Physicians obtains preauthorization in writing within 5 days of physical therapy, certain psychiatric tests, or MRIs
- No alternative for services available within 25 miles or a 40 minute drive and physicians makes full disclosure about financial interest in these services
79
Substantial evidence
Concept by shich medical reports are measured
80
Standards for determining if a report has substantial evidence
- Predicated on reasonable medical probability
- Not based on facts no longer germane, inadequate medical history/exams, incorrect legal theories or on surmise, speculation, conjecture, or guess
- Set for reasoning behind opinions (not merely conclusions)
- Disclosures of familiarity with concept of apportionment, and context of apportionment determinations
81
Types of reports
- Comprehensive (first)
- Follow-up
- Supplemental
82
Factual correction
- Type of supplemental report confined to review of the medical records in possession of the QME at the time of the evaluation
83
Time limits for unavailability by QMEs
14 - 90 days
84
Timeframe in which QMEs must notify medical director of unavailability
At least 30 days before the period of unavailability begins
85
Good cause for periods of unavailability longer than 90 days during the QME calendar year
- Sabbaticals
- Death/serious illness of an immediate family member
86
Time limit for an initial or follow-up evaluation
- 30 days after the evaluation
- Extension no more than 30 days
87
Time limit to coplete and serve a supplemental report
- 60 days after the date ofa request to the QME
- Extension can be no more than 30 days
88
Timeframe to review corrections and determine if factual corrections are necessary
- 10 days after service of request for factual correction, if filed by the worker
- 15 days after service, if filed by the claims administrator or by both parties
89
To whom are reports serviced for represented workers (comprehensive, follow-up, or supplemental)
- Worker
- Attorny, claims adminstrator, employer
90
To whom are reports serviced for unrepresented workers (comprehensive, follow-up or supplemental)
- Worker
- Claims administrator (employer if no CA)
91
To whom are reports serviced for unrepresented workers (permanent impairment, permanent disability, apportionment)
- Assigned disability evaluation unit (DEU) office
- Worker
- Claims administrator (employer if no CA)
92
To whom are reports regarding psychiatric injury serviced
Injured worker directly, or on a designated physician for the purpose of reviewing and disuccing the eval with the worker
93
Timeframe for retention of reports by QME
5 years from the date of report (may retain a signed electronic copy)
94
My QME
flashcards
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