Module3_Flashcards_Part1

Question 1

Front

Answer 1

Back

Question 2

What is the main purpose of medical-legal reporting in California workers’ compensation?

Answer 2

To resolve disputes about injury, treatment, disability, and causation using objective medical evidence.

Question 3

Who typically writes medical-legal reports in workers’ comp cases?

Answer 3

Qualified Medical Evaluators (QMEs) or Agreed Medical Evaluators (AMEs).

Question 4

What must every medical-legal report include at the start?

Answer 4

A physician’s declaration affirming the report is true, complete, and complies with DWC regulations.

Question 5

What patient history must be included in medical-legal reports?

Answer 5

Detailed work injury history, medical history, and relevant non-industrial factors.

Question 6

What physical exam info is required in a QME report?

Answer 6

Objective findings, measurements, and consistency with reported symptoms.

Question 7

What imaging or test results must be included?

Answer 7

All reviewed diagnostic studies and how they support or refute injury claims.

Question 8

What is Maximum Medical Improvement (MMI)?

Answer 8

When the injury is stable and unlikely to improve substantially with more treatment.

Question 9

What must be stated about future medical care in a QME report?

Answer 9

Whether ongoing or future care is necessary and what type.

Question 10

What is apportionment in medical-legal reporting?

Answer 10

Dividing permanent disability between work-related and other causes.

Question 11

What is substantial medical evidence?

Answer 11

Opinion based on reasonable medical probability, adequate history, exam, and reasoning.

Question 12

What standard guides permanent impairment ratings?

Answer 12

AMA Guides to the Evaluation of Permanent Impairment, 5th Edition.

Question 13

What is Whole Person Impairment (WPI)?

Answer 13

Percentage showing how an injury affects overall functioning.

Question 14

What must be disclosed about work restrictions?

Answer 14

Specific functional limits (e.g., lifting, standing) that impact job duties.

Question 15

What if records are missing or incomplete?

Answer 15

Note missing info, explain effect on opinion, and may request additional records.

Question 16

When must a supplemental report be issued after request?

Answer 16

Within 60 days unless parties agree otherwise.

Question 17

What happens if a QME report is late without good cause?

Answer 17

Payment may be denied and DWC may discipline the evaluator.

Question 18

What is the time limit to issue the initial QME report?

Answer 18

Within 30 days of the evaluation unless extended.

Question 19

Who approves extensions for late QME reports?

Answer 19

The Division of Workers’ Compensation (DWC) upon good cause request.

Question 20

How soon must parties serve medical records to the QME?

Answer 20

At least 20 days before the exam; disputes must be resolved timely.

Question 21

Can QMEs treat the injured worker they evaluate?

Answer 21

No, they must remain independent and not provide treatment.

Question 22

Who pays the QME for medical-legal evaluations?

Answer 22

The employer or insurer.

Question 23

What is an Agreed Medical Evaluator (AME)?

Answer 23

A doctor chosen jointly by both parties to replace the QME panel process.

Question 24

When can AME be used instead of QME?

Answer 24

Only if the worker has an attorney and both sides agree on the doctor.

Question 25

What is the role of the Disability Evaluation Unit (DEU)?

Answer 25

It rates permanent disability based on medical reports to set benefits.

Question 26

What is functional capacity evaluation (FCE)?

Answer 26

Testing to measure a worker’s physical abilities and job limitations.

Question 27

What is utilization review (UR)?

Answer 27

Insurer’s process to decide if requested medical treatment is necessary.

Question 28

What is independent medical review (IMR)?

Answer 28

State-run process to resolve disputes over denied treatment after UR.

Question 29

What is the time limit to request IMR after UR denial?

Answer 29

Usually within 30 days of the denial notice.

Question 30

Who oversees the IMR process in CA?

Answer 30

The California Department of Industrial Relations (DIR).

Question 31

What is causation in medical-legal context?

Answer 31

Determining if the work injury substantially caused the condition (≥35–40%).