Study Guide Cards

Question 1

QMEs rate what? impairment or disability.

Answer 1

impairment, they DO NOT rate disability.
Raters rate disability.

Question 2

How do Raters rate disability?

Answer 2

Raters use the QME impairment rating and convert it into a disability rating.

Question 3

The California Work Comp System is based on the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition for cases P+S on or after 1/1/05. What is the exception?

Answer 3

A. Exception: Psych falls outside of the AMA guides, it
is rated based off the GAF (Global Assessment of
Functioning) score

B. Cases P+S prior to 1/1/05 should be rated on the 1997
PDRS (based on work restrictions)

Question 4

QME Requirement: At least 1/3 of a QME’s time must be
devoted to direct medical treatment. The only exceptions are:

Answer 4

A. If the QME has been an AME 8 times in the past year

B. If the QME is a retired, teaching or disabled physician

Question 5

Acupuncturists can issue opinions on Permanent
Disability. True or Flase

Answer 5

False

Acupuncturists cannot issue opinions on Permanent
Disability.

Question 6

How many locations can a QME list for work?

Answer 6

QMEs are limited to listing 10 locations for QME work.

Question 7

True/ false

QMEs are allowed to treat the injured worker,

Answer 7

QMEs are NOT ALLOWED to treat the injured worker, unless the injured worker requests it or under emergency situations.

Question 8

When can a QME offer opinions on care?

Answer 8

QME can only offer opinions only on areas in which s/he is an expert

Question 9

Apportionment applies ONLY to what? And is
based on What?

Answer 9

Apportionment applies ONLY to Permanent Disability and is based on CAUSATION.

Question 10

When is treatment, or work restrictions apportioned?

Answer 10

ONLY Permanent Disability is apportioned,
never apportion treatment, work restrictions or anything else.

Question 11

Evaluation Protocols:

What The are 6 protocols for injuries occurring before 1/1/2005:

Answer 11

1. Neuromusculoskeletal
2. Psychiatric
3. Cardiac
4. Foot & Ankle
5. Pulmonary
6. Immunological

Question 12

Post 1/1/2005, where are the evaluation protocols contained?

Answer 12

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

Question 13

Who can sign evaluation reports and what must be included

Answer 13

Must be signed by QME, on the date the report was completed (not evaluation date) and include county report was signed in.

Question 14

When is Disciplinary Action used on the QME?

Answer 14

1. Consistently submitting late reports
2. Lack of availability
3. Ex Parte communications
4. Self-referral
5. Prepares reports that do not meet DWC minimum standards

Question 15

True or False

QME’s opinion must be speculative in nature.

Answer 15

QME’s opinion must NOT be speculative, it must be based on pertinent facts and on an adequate examination and history.

Question 16

With an HPI, what needs to be included in discussion?

Answer 16

With an HPI, need to include discussion of mechanism of injury

Question 17

what are the Main Types of WC Benefits?

Answer 17

1. Medical Treatment
2. Temporary Disability Benefits
3. Permanent Disability Benefits
4. Death Benefits
5. Supplemental Job Displacement Benefits (SJDB)

Question 18

Boynton Act of 1913 requires

Answer 18

California employers to have
WC insurance“

Question 19

What are the 3 types of “Grand Compromise” between employers and employees

Answer 19

a. No Fault
b. Exclusive Remedy
c. Assured and Fixed Benefits

Question 20

Medical-legal report definition:

Answer 20

To prove or disprove an aspect of a contested claim.

Question 21

Physician definition:

Answer 21

Not only includes MD’s and DO’s but also, podiatrists, dentists, chiropractors, acupuncturists and optometrists.

Question 22

Impairment ratings:

Answer 22

rate the degree to which the impairment
decreases an individual’s ability to perform activities of daily
living, excluding work.

Question 23

Causation of Injury definition:

Answer 23

Arising out of employment or through the course of employment (AOE/COE)

Question 24

Ex Parte communication definition:

Answer 24

“Ex parte” is a Latin phrase meaning “on one side only; by or for one party.”

Question 25

An ex parte communication occurs when

Answer 25

a party to a case communicates with 1 side only. A QME CANNOT communicate information with one side and not the other. However, QME’s can communicate with the treating Physicians if questions arise.

Question 26

What is the difference between Exacerbation vs. Aggravation:

Answer 26

a. Exacerbation is a TEMPORARY increase in symptoms causing no new permanent disability (not a new injury) b. Aggravation is an increase in symptoms with an increase in permanent disability (a new injury)

Question 27

Injury definition:

Answer 27

Incident or exposure that causes disability or need for medical treatment

Question 28

What are the different types of injuries?

Answer 28

a. Specific Injury: Occurring as a result of one incident or exposure b. Cumulative Trauma: Repetitive traumatic injury

Question 29

True or False An injury requiring only first aid does not qualify as an “injury” under WC

Answer 29

True An injury requiring only first aid does not qualify as an “injury” under WC

Question 30

What are the injury exclusions?

Answer 30

injuries arising out of intoxication, while committing a crime, suicide, intentionally self-inflicted injuries, initial physical aggressor, off-duty recreational activities, psych injuries after termination

Question 31

Impairment definition:

Answer 31

Loss, loss of use or derangement of any body part, organ system or organ function.

Question 32

Permanent vs. Temporary Disability:

Answer 32

a. Permanent Disability: irreversible residual of an injury b. Temporary Partial Disability: Can do some work, but earning less than prior to injury c. Temporary Total Disability: Cannot work at all.

Question 33

Apportionment Definition: Substantial Medical Evidence Definition: QME’s opinion must be predicated on reasonable medical probability. Explain your reasoning. DO NOT JUST STATE CONCLUSIONS.

Answer 33

An estimate of what percent of permanent disability was caused by a work-related injury and what percent was caused by other factors.

Question 34

Substantial Medical Evidence Definition

Answer 34

QME’s opinion must be predicated on reasonable medical probability. Explain your reasoning. DO NOT JUST STATE CONCLUSIONS.

Question 35

Temporary Disability Payments:

Answer 35

a. 2/3 of average weekly pay b. Limited at 104 weeks/2 years

Question 36

Supplemental Job Displacement Benefits

Answer 36

If employer does not offer RTW, IW may be eligible for a voucher. Voucher must be used within 2 years of issue or 5 years after Date of Injury (DOI), whichever is later.

Question 37

Injury Compensability:

Answer 37

a. Non-Psych injuries compensable if 1% or more of the injury is industrial b. Psych injuries compensable if predominantly (i.e. > 50%) industrial with some exceptions.

Question 38

What are some of the know presumptions

Answer 38

a. Firefighters and peace officers, cancer, if known exposures b. For peace officers “heart trouble and pneumonia” and lower back if worked at least 5 years. Also, hernia, infectious diseases (Hep B, Hep C, HIV, MRSA, TB, meningitis) c. Actual vs. Perceived Events of Employment: Needs to actually have happened. Worker will not receive benefits for perceived events of employment.

Question 39

What are the MTUS (Medical Treatment Utilization Schedule) guidelines:

Answer 39

a. ODG – Chronic Pain/Post-Surgical b. ACOEM – everything else

Question 40

What is the signifigance of the date January 1, 2005

Answer 40

The date that SB899 went into effect and the California work comp system moved to the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition a. If the Injured worker (IW) is P+S on or after 1/1/2005, use the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition to rate impairment b. If the Injured Worker (IW) is P+S before 1/1/2005, use the 1997 PDRS (Permanent Disability Rating Schedule) and rate on work restrictions

Question 41

What is the signifigance of the date January 1, 2013?

Answer 41

The date that SB863 went into effect. This law placed restrictions on the ability for injured workers to receive impairment for compensable consequence psych, sexual, or sleep disorders.

Question 42

Initial evaluations and Follow-Up Evaluations:

Answer 42

in 30-days from date of evaluation

Question 43

When are Supplemental Reports due?

Answer 43

Due in 60-days

Question 44

How long are Report supposed to be kept?

Answer 44

MUST be kept for 5-years.

Question 45

How long after a Appointment Scheduling does the QME have to respond?

Answer 45

within 90-days of the phone call.

Question 46

Appointment Notification Form (Form 110) must be filled out when?

Answer 46

within 5 business days of making an appointment.

Question 47

Conflict of Interest (COI): What should a QME do if there is a COI?

Answer 47

A QME must disqualify themselves if there is a conflict of interest. Must be disclosed to all parties, in writing. within 5-days of becoming aware of the COI.

Question 48

What are the Conditions for Medical Evaluations Extensions?

Answer 48

a. Waiting for test results or consulting physician’s reports – 30-day extension b. All else with “Good cause”– 15-day extension

Question 49

Minimum required face-time with injured worker (for uncomplicated evals):

Answer 49

a. Neuromusculoskeletal – 20 mins b. Cardiology – 30 mins c. Pulmonology – 30 mins d. Psych – 60 mins e. Everything else – 30 mins

Question 50

Progress Reports: A Primary Treating Physician (PTP) must submit a PR-2 (Progress Report) to the claims administrator to document, at minimum of what time range?

Answer 50

every 45 days. It is also required whenever there is a change in work restrictions or work status, a change in the patient's condition, or a new treatment is recommended.

Question 51

What are the requirments of an Unavailable QME?

Answer 51

* If QME will be unavailable for over 14-days and up to 90-days, the QME must notify the DWC at least 30-days prior with Form 109

Question 52

How are QME appointment cancellations handled?

Answer 52

A QME cannot cancel and exam within 6 business days of evaluation unless there is “good cause” and MUST provide a provide a new exam date within 30 calendar days of the date of cancellation and 60 days of the date of the call to schedule.

Question 53

Depositions have to be scheduled in how much time after notice?

Answer 53

have to be scheduled within 120 days of notice unless WCAB/WCALJ orders otherwise or parties agree.

Question 54

Carrier has how many days to accept or deny a claim?

Answer 54

90-days to accept or deny claim from date of notice, if carrier does not deny within 90 days then claim is considered compensable.

Question 55

The first treating physician to see an injured worker must do what?

Answer 55

complete a Doctor’s First Report of Occupational Injury or Illness within 5 days of the injured worker’s first visit

Question 56

FORM 100

Answer 56

Employee’s Disability Questionnaire: must be included for reports for unrepresented IW but only when report addresses permanent disability or apportionment

Question 57

FORM 101

Answer 57

Request for Summary Rating Determination: must be included for reports for unrepresented IW but only when report addresses permanent disability or apportionment

Question 58

FORM 109

Answer 58

Notice of Unavailability Form, must be filed at least 30 days prior to period of unavailability, a QME is permitted a maximum of 90 days of unavailability in a year

Question 59

FORM 110

Answer 59

Appointment Notification Form, must be sent by QME to all parties (i.e. AA, DA, Injured Worker, IC/Adjuster) within 5 business days of the scheduling of an appointment

Question 60

FORM 111

Answer 60

QME Findings Summary Form: must be included for reports for unrepresented IW

Question 61

FORM 112

Answer 61

QME/AME Report Time Frame Extension Request: must be filed at least 5 days before due date of report, you get a 15-day extension for “good cause” (e.g. illness/death of you/family, natural catastrophe, etc.) or 30 days extension for late consultation report/testing results

Question 62

FORM 122

Answer 62

Medical-Legal Declaration of Service Form: must be included for reports for represented IW

Question 63

What are Service of QME Report Forms Requirements?

Answer 63

a. Represented: FORM 122 b. Unrepresented: * DOES NOT address PD or apportionment: FORM 111 * DOES address PD or apportionment: FORM 100, FORM 101, FORM 111

Question 64

What are the Service of QME Report for Psych Specific Forms requirments?

Answer 64

Determine if Injured Worker (IW) would like the report sent to them or to a Physician: * IW wants Psych report sent to Physician instead of self: FORM 120 * IW wants Psych report sent to self: a. Viewing report IS a risk to IW: FORM 121 b. Viewing report IS NOT a risk to IW: Send report to IW

Question 65

Labor Code 3208.3: Psych Injuries

Answer 65

a. Psych injuries compensable if predominantly (i.e. > 50%) industrial with some exceptions: * Violent Psych injuries need only be substantially industrial (35%) in order to be compensable * Psych Injuries that are substantially (at least 35%) caused by personnel actions (good faith, non-discriminatory, lawful) are noncompensable ▸ Rolda analysis * Must be due to actual events of employment (not perceived) ▸ Verga Decision * IW must be employed at least 6 months in order to have a compensable psych claim ▸ Exception: “Sudden and Extraordinary Circumstances” compensable with less than 6 months employment * Post-termination psych claims are generally barred

Question 66

With Labor Code 3208.3 Psych Injuries what is the Rolda analysis?

Answer 66

▸ Rolda analysis * Must be due to actual events of employment (not perceived)

Question 67

With Labor Code 3208.3 Psych Injuries what is Verga Decision?

Answer 67

* IW must be employed at least 6 months in order to have a compensable psych claim ▸ Exception: “Sudden and Extraordinary Circumstances” compensable with less than 6 months employment * Post-termination psych claims are generally barred

Question 68

Almaraz/Guzman

Answer 68

a. If the physician believes that the standard impairment rating does not accurately characterize the level of impairment, then physician may use an alternative chapter of the AMA Guides to more accurately rate the impairment provided the physician explains why the deviation is necessary

Question 69

Escobedo v. Marshall

Answer 69

a. Provided guidelines for addressing apportionment: * Based on causation of disability NOT causation of injury * What % is caused by industrial factors and what % is caused by other factors b. Provided guidelines for substantial medical evidence: * Must be based on reasonable medical probability

Question 70

Benson v. WCAB

Answer 70

a. If a case has multiple dates of injury (DOI), Permanent Disability must be apportioned amongst the various dates of injury. b. If this cannot be determined with reasonable medical probability then one can opine that the dates of injury and the impairment are all inextricably intertwined.

Question 71

When did SB899 go into effect?

Answer 71

Went into effect January 1, 2005

Question 72

When did SB863 go into effect?

Answer 72

Went into effect January 1, 2013 (see key dates section for more)

Question 73

Why is LC 4628 so important?

Answer 73

a. If you fail to comply with the requirements of LC 4628 the report is inadmissible and there is no liability for med-legal expense. b. Attestation under penalty of perjury that everything in the report is true and correct to best of your knowledge c. Include the 4628(j) disclosures in all your reports and remember to sign in the county you completed the report in

Question 74

Why is LC 139.3 so important?

Answer 74

a. Bars physician from self-referring b. Include the 139.3 disclosure in all your reports, if you don’t the report is inadmissible and there is no liability for the med-legal expense.