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QME Extra studying Flashcards

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1
Q

How are communications between parties and a QME conducted prior to an
examination?

A

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

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2
Q

Regarding all records prepared or maintained by the employee’s treating
physician(s), which party may provide this information to the QME?

A

Any Party

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3
Q

Regarding other medical records, including any previous treatment records or
information, which are relevant to determination of the medical issue in dispute,
which party may provide this information to the QME?

A

Any Party

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4
Q
  1. Regarding non-medical records, including films and videotapes, which are relevant to determination of medical issue(s) in dispute; which party may provide this information to the QME?
A

Any Party

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5
Q

Should a QME assume medical records are correct

A

Yes

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6
Q

A letter is sent to the QME before an evaluation stating that compensability is the contested issue in the case; which party may provide this information to the QME?

A

Any party

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7
Q

A party supplying information to the QME must serve the same information to the opposing party how many days before the information is provided to the QME?

A

20 days

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8
Q

How many days, upon receipt of non-medical records from party A, does party B
have to object-to and block sending non-medical records to the QME?

A

10 days

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9
Q

Would a QME be sent any medical/legal report which has been rejected by a
party as untimely?

A

In no event should the QME be sent this information

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10
Q

Should a QME be sent any evaluation or consulting report that has been stricken
or found inadmissible by a WCAB (Workers’ Compensation Appeals Board)
administrative law judge?

A

In no event should the QME be sent this information

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11
Q

Can a QME be sent any medical report or record or other information or thing
which has been stricken, or found inadequate or inadmissible by a WCAB
(Workers’ Compensation Appeals Board) administrative law judge or which
otherwise had been deemed inadmissible to the evaluator as a matter of law?

A

In no event should the QME be sent this information

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12
Q
  1. If a party fails to provide a QME with any relevant medical records which the
    QME deems necessary to perform a comprehensive medical-legal evaluation, what may the QME do?
A

The evaluator may contact the treating physician or other health care providers to obtain such record(s).

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13
Q

If a party fails to provide a QME with relevant medical records within 10 days after the date of the evaluation, and the evaluator is unable to obtain the records, what should the evaluator do?

A

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.

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14
Q

If a QME submits a report where records were not received from the parties and
then the records are received, when can the evaluator submit a supplemental
evaluation?

A

Upon request by either party or the Worker’s Compensation Appeals Board
(WCAB)

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15
Q

Parties select an AME to settle disputes. Which party decides what information is
sent to the AME?

A

Both parties must agree on the information that is sent to the AME

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16
Q

A QME collects a history from the injured worker however, the history based upon the medical records is different. What should the QME do in the report?

A

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 ot
the history

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17
Q

True or false: A QME should not collect a history in regards to how an injured
worker gets to work, how much the injured worker has lost in wages, or
information about the injured workers’ family members’ work histories. The QME should collect information about what occurred immediately after the work injury.

A

TRUE

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18
Q

A letter is sent to the QME before an evaluation stating that compensability is the contested issue in the case; which party may provide this information to the QME?

A

Any party

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19
Q

Permanent and Stationary
Definition

A

When a condition reaches a state of maximal medical improvement

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20
Q

Escobedo case

A

-Set standard of reasonable medical probability (standard a physician is
expected to follow, that’s based on superior evidence, something is probably
/more likely than not)
These works turn the report into substantial evidence

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21
Q

Roldán issues/Limits on compensability of psych issues

A
  1. Did psycho injury involve “actual events of employment”? (IW has burden of proof)
  2. Is there >50% industrial causation (IW burden)
  3. Was there personnel action and was it lawful,
  4. Were personnel actions the substantial (>35% - 40%) cause of the psych
    injury. (Defense burden)
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22
Q

Granado case

A

Set the standard that medical tx (MT) is not apportionable

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23
Q

Benson case

A

-Clarified parsing out impairment to different injury dates
-If they can’t be parceled out, you can say they are “inextricably intertwined.”

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24
Q

Guzman case/Almaraz-Guzman standard

A

-Alternative rating of disability when case is complex/extraordinary, and AMA
guides doesn’t accurately reflect the persons impairment)
- WPI rating can be made if it’s accurate and based on AMA guides (fairness is
not allowed anymore)

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25
Blackledge v B of A WCAB defined roles for:
-physician -DEU rater -parties -Work comp judge
26
Blackledge case: physician requirements
1. Compare medical findings 2. List WPI for each med condition 3. Select impairment in the range based on impact on ADLs 4. ADL analogies - Role of evaluator is to assess WPI % by a report that sets forth facts and reasoning to support conclusions and are in line with AMA & case law.
27
Alternative rating under Almaraz/Guzman
1. Begin w strict rating found in the chapter address the injured body part 2. Explain what specific facts require an alternative rating 3. Provide analysis as to why alternative rating is more accurate 4. Set forth how Dr. arrived at alt rating State position with reasonable medical probability
28
Original intent of WC
1. Provide minimum level of benefits promptly 2. To prevent IW from becoming a burden on others and help IW return to work thru rehab 3. Help dependents if IW dies 4. MT for job related injuries/illness 5. TD benefits for lost wages 6. PD benefits for finished ability to compete in the open labor market.
29
Boynton Act
-1913: require most employers to have WC coverage -Later expanded to include a provision that when rating disability, persons' diminished ability to compete in the open job market should be considered
30
Historic compromise
-Trade-off of rights and benefits -Employee give up right to sue for lots of $ and gets protection from legal system against discrimination -Employer provide benefits regardless of fault in exchange for protection from lawsuits - 3 components 1. No fault 2. Exclusive remedy 3. Assured and fixed benefits
31
No Fault & exceptions
- Employer pays benefits no matter who caused injury, as long as it occurred during employment * Exceptions -self inflicted injury -injury from serious/willful misconduct by employee benefits reduced by half unless employee died or has PC of 70% or more -injury from failure of employer to comply with health and safety reg -employee was under 16 years old.
32
Exclusive Remedy
Workers’ compensation benefits are the only benefits injured workers may receive to compensate for a work-related injury. (Even if employer negligent) -unless employer uninsured -or third party is involved, that party can be sued
33
Assured & Fixed Benefits
-WC has defined benefits employer must pay -WC is a statutory benefit with no arbitrary limits on frequency, duration, or extent of services.
34
Benefits provided by WC system
-Medical -TD payments: paid while injury is being TD, before it is PD -PD payments determined by loss of ADLs that contribute to WPI; compensates employees for not fully recovering. -Vocational: no longer; now provides Supp Job Displacement Benefits (SJDB) -Death: q dep: $125,000, 2 dep: 135,000, 3+ dep: 160,000
35
Claims adjudication Unit
WC Judges and staff, first level in determining claim
36
Disability eval Unit
Disability evaluator/raters that determine PD ratings
37
Info and Assistance Unit
-Assists on rights, benefits, and obligations under CA WC laws - Officer helps resolve misunderstandings, disputes, and complaints from claims for compensation.
38
Rehab Unit
Makes determinations of disputes in vocational rehab
39
Audit and Enforcement Unit
Conducts audits on insurance companies, elefante insured employers, and 3rd party administrators; ensures benefits are pain accurately and timely.
40
Uninsured employer fund/Collections unit
Pays benefits to IW w/ illegally uninsured employer & pursuers recovery
41
Medical Unit
-Executive med director; performs services related to delivery of med benefits -Est. Policy and guidelines for tx and eval of IW - Appoints QMEs; investigates complaints on QMEs - Approves/certifies and oversees MPNs and HCO - Helps set a med fee schedule.
42
DEU ratings
1. Formal: done at request of WC judge 2. Consultative: done on litigated cases at request of attorney or DW info assist officer 3. Summary: non-litigated castes at request of claims administrator or IW.
43
Workers Comp Info System (WCIS)
-Uses electronic record keeping data to collect info from claims admin to help DIR oversee WC system - All elements/documents of claim (reports, notices, med billing) are required to be electronic as of
44
Subsequent injury benefits trust fund (SIBTF)
-Source of add. Compensation for IW who already had disability at time of injury. -Need combined effect of at least 70% Employees can hire disabled workers w/o fear of liability for effects of prev. Disability.
45
WCAB
Workers Comp Appeals Board: 7 commissioners, 5 of which are attorneys -independent judicial body w/in DIR -adopt rules of procedure -set policies -interpret regulations -review petitions for reconsiderations of decisions made by WC judges.
46
DIR
Department of Industrial Relations
47
DWC
Division of Workers’ Compensation djd -State of CA > Dept of Consumer Affairs > DIR > DWC> Medical Unit > QME
48
Statute v. Regulation
1. Defines eligibility, types and levels of benefits, system operation; written by legislature and signed by governor 2. Specifics, day to day operation of WC system (time limits, contents of reports) Statutes are laws enacted by legislative bodies (like Congress or state legislatures), while regulations are rules and administrative codes issued by governmental agencies to implement and enforce those statutes.
49
Burden of proof
-preponderant of the evidence -Prove that your position is MORE LIKELY THAN NOT to be correct -if met, you are providing substantial evidence
50
Who has the burden of proof?
-Applicant: preponderance of the evidence -Shifts to defense if non-discriminatory, good-faith personnel action
51
Burden of proof for apportionment
Up to the employer to prove
52
35. Presumptions (burden of proof)
Remove burden of going forward and place burden onto opposing party -Firefighters and peace officers: cancer -Peace officers: heart trouble, pneumonia if served 5 years.
53
Rebuttable presumption
-Evidence can overcome presumption -Burden is on employer to show by preponderance of evidence that the injury is not work related (e.g. heart problem in PO caused by drug use)
54
Injury (work comp)
-injury or disease arising out of employment -injury caused by TD of an injury arising out of employment -Any side effect from preventative healthcare provided by employer -Must cause disability or needs medical tx -Must lose work time/impact ability to work
55
Specific injury
Injury caused by single incident or exposure; single need for medical tx
56
Cumulative injury
Repetitive trauma (mental or physical) over period of time
57
Occupational disease
-Illness resulting from conditions associated with employment -Can also have been contracted outside of work (TB) -Minor industrial injury -Cumulative trauma d/o (multiple insults to musculoskeletal system over time) -Exposure to chemical agents, noise, cold, radiation, repetitive motion
58
First aid tx
-1x treatment -Allows for f/u or observation; provided by physician or registered professional -Employer does not need to provide claim form or submit employers 1st report -Physician need to complete Drs 1st report -* Tx for pesticide poisoning (or suspected) is NEVER considered first aid.
59
Compensable injury criteria
-Have injury (phys or psych) -Employment relationship For Internal Use Only -Injury caused by employment (AOE – rising out of employment) -COE (occurring in course of employment)
60
Non-psych injury % cause for compensability
1%
61
Psych injury % cause for compensability
51%
62
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