QME EXAMS 2024/2025 with 100% CORRECT VERIFIED ANSWERS GRADED, Exams of Health sciences

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QME EXAMS 2024/2025 with 100% CORRECT VERIFIED ANSWERS GRADED Holds authority to appoint physicians as QME evaluators Administrative Director (AD) (LC 139.2) Term of appointment as QME evaluator 2 years (LC 139.2) 3 requirements when seeking appointment as QME (1) Pass the QME competency exam; (2) Complete a 12-hour course in disability eval report writing; (3) Devote at least 1/3rd of total practice time to providing direct medical treatment (or have served as a AME on 8+ occasions in past 12 mos prior to application) 2 reasons for termination/suspension of a QME w/o a hearing (1) Licensing board suspends/revokes/terminates license to practice (2) Failure to pay required fee (upon appointment and yearly thereafter) 6 reasons for discipline (suspension/termination) of QMEs after a hearing (1) Violation of material statutory or administrative duty; (2) Failure to follow medical procedures or qualifications; (3) Failure to comply with the timeframe standards; (4) Failure to meet licensing/certification requirements; (5) Preparation of medical-legal evaluations that fail to meet the minimum standards for those reports as established by the administrative director or the appeals board; (6) Making material misrepresentations or false statements in an application for appointment or reappointment as a qualified medical evaluator. 3 types of substantive medical disputes resolved by QMEs constitute part of the employee's work-related duties and the activity is not an expressed or implicit condition of employment; (7) Psychiatric injuries claimed after notice of termination/layoff unless certain conditions exist 4 basic conditions to establish a workers' compensation claim (1) Injury (physiological or psychological harm); (2) Employment relationship; (3) Injury caused by the employment (This is also referred to as arising out of employment [AOE].); (4) Occurred in the course of the employment (COE) Aggravation of a pre-existing, non-industrial condition (1) Causes a temporary or permanent increase in disability; (2) Creates a new need for medical treatment; or (3) Requires a change in the existing course of treatment Symptoms that don't constitute a new injury Flare-ups or recurrence of a previous industrial injury or illness; not been caused by the current employment Date of injury (DOI)-specific injury Date on which the incident or exposure occurred Date of injury (DOI)-cumulative injury Date when 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 Items determined by the DOI (1) Statute of limitations for particular procedures within the workers' compensation system; (2) Regulations that will apply to the worker's injury; (3) Compensation rate for the worker's injury; (4) Employers who are liable for the claim. Reasonable medical probability Standard by which QME uses combination of existing medical and scientific knowledge and the occupational and medical history of the individual worker to conclude whether the work exposure contributed to the injury Evidentiary standard of causation/contribution in compensability disputes Preponderance of the evidence (51%; more likely than not) 3 factors to establish in making a causation determination (1) Presence of pathological conditions and disability (2) Relevant work exposures (3) Non-industrial exposures (other causes of disease) 5 major types of causation (1) Direct (2) Contributing (3) Acceleration (4) Precipitation (5) Aggravation Direct causation Work exposures are directly responsible for the health outcomes Contributing causation Several factors led to the disease; work exposure is one of these factors Acceleration Proximate cause Causal connection between injury and employment *Employment need not be sole cause of injury, just a contributing cause Criteria for compensability of psychiatric claims after notice of termination/layoff (1) Injury was the result of sudden and extraordinary events of employment (2) Employer had notice of the injury before the notice of termination or layoff. (3) Medical records existing before the notice of termination/layoff contain evidence of treatment of the psychiatric injury (4) Contractual, administrative, regulatory, or judicial trier of fact has found that there was sexual or racial harassment. (5) There is evidence that the DOI is subsequent to the date of notice of termination, but before the effective date of the termination. (Allows post-termination claims for cumulative injuries or occupational illnesses that do not manifest themselves until after the employee has left the job) First right to request a QME examination to determine compensability Injured worker, regardless of representation First right to specify specialty of the QME panel Injured worker, regardless of representation Admissible reports before a WCJ to resolve the issue of compensability (1) Properly acquired QME (2) Primary treating physician Permanent disability rating (determination) (1) The disability evaluation (2) A rating schedule that correlates impairment with disability (Schedule for Rating Permanent Disabilities) Impairment rating (determination) Physician, using AMA Guides Responsibility of assigning the permanent disability rating A rating specialist in the Disability Evaluation Unit (DEU) of the DWC (**not physicians**) (10) Respiratory system (11) All other systems/regions Criteria for presumptive 100% awards (1) Loss of both eyes or sight in both eyes (2) Loss of both hands or use of both hands (3) Injury resulting in practically total paralysis (4) Injury to the brain, resulting in incurable mental incapacitiy or insanity Trigger for a comprehensive medical evaluation of permanent disability by an AME/QME Injured worker or employer wishes to contest treating physician's evaluation Impairment (AMA Guides definition) Loss, loss of use, or derangement of any body part, organ system or organ function Change from a normal/pre-existing state implied in def'n Disability (AMA Guides definition) Alteration of an individual's capacity to meet personal, social, or occupational demands or statutory or regulatory requirements because of an impairment Combined Values Chart Used to combine multiple impairment ratings into a summary value or WPI Responsibility for assigning QME panels DWC Executive Medical Director Time frame in which either party in represented cases may object to a medical determination by the treating physician 20 days, in writing Time frame in which either party in unrepresented cases may object to a medication determination by the treating physician 30 days, in writing Time limit for unrepresented injured worker to submit request for a QME panel after receiving form from employer 10 days Time frame after which unrepresented worker has the right to obtain an evaluation from any QME within a reasonable geographic area After 20 days, if request for QME panel is not issued 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 Rights of the claim administrator in selecting the QME and arranging the appointment If injured worker does not inform the claims administrator of the selection or date of appointment Time frame in represented cases during which each party may strike one name from the QME panel 10 days after the assignment of the panel Time frame in which selected QME must schedule an appointment to see the injured worker Within 60 days of a request for an appointment (up to 90 days) Time frame to submit the QME Appointment Notification Form Within 5 business days of making the appointment Parties receiving service of the QME Appointment Notification Form issue requested to address in the evaluation (4) 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 (5) Non-medical records relevant to determination of medical issue(s) in dispute Time frame for service 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 Time frame to object to sending of non-medical records to the selected QME Within 10 days Info which should never be sent to the selected QME (1) Any medical/legal report rejected by a party as untimely (2) Evaluation/consulting report written by a physician other than the treatment physician that addresses permanent impairment, permanent disability, or apportionment (unless ruled admissible by a WCALJ) (3) Any medical report/record or other info stricken or found inadequate/inadmissable by a WCALJ Ex-parte contact Any communication--written or oral--by one party (or their representative) with the evaluator outside of the presence of the opposing party Conflict of Interest (COI) An evaluator may not request or accept any compensation or other thing of value from any source that does or could create a conflict with his or her duties as an evaluator Persons/entities with whom a QME may have a disqualifying COI (1) Injured worker (or their attorney) (2) Employer (or their attorney) (3) Claims administrator (or their attorney) (4) Primary/secondary treating physician, if treatment by physician is being disputed (5) UR physician reviewer or expert reviewer or UR organization if decision is being disputed (6) Surgical center if surgery is being disputed (7) Purveyor of medical goods/svcs if goods/svcs are being disputed Good cause for discontinuing a comprehensive medical-legal evaluation by a QME (1) Injured worker/representative uses abusive language towards the evaluator/evaluator's staff; (2) Injured worker/representative deliberately attempts to disrupt the operation of the evaluator's office in any way; (3) Injured worker is intoxicated or under the influence of any medication which impairs the injured worker's ability to participate in the evaluation/process. Face-to-face time Only time evaluator is present with an injured worker, taking a history, performing a physical exam or discussing the worker's medical condition with the worker Minimum face-to-face time requirements for uncomplicated evaluations 20 minutes for neuromusculoskeletal evaluations 60 minutes for psychiatric evaluations 30 minutes for all other evaluations Required contents of report (1) Date of examination; (2) Street address at which examination was performed; (3) All contested medical issues arising from all injuries reported on one or more claim forms prior to the appointment that are within the evaluator's scope of practice and areas of clinical competence; (4) Disputed issues beyond the evaluator's expertise; Parties who may participate in the non-clerical preparation of the medical-legal report Evaluating physician (who signs the report) Unallowed referrals (1) Outside referrals in which the physician or physician's family has a financial interest; (2) Cross-referral rearrangement or other scheme whose primary purpose is to ensure referrals; (3) Any kind of compensation or inducement for referred evaluations or consultations. Exceptions to disallowed referrals (1) Physician discloses financial interest in referred services to patient; (2) Physician obtains preauthorization in writing within 5 days for physical therapy, certain psychiatric testing or MRIs; (3) No alternatives for service available within 25 miles or a 40-minute drive and physician makes full disclosure about financial interests in these services. Substantial evidence Concept by which medical reports are measured Standards for determining if a report is substantial evidence (1) Predicated on reasonable medical probability; (2) Not based on facts no longer germane, inadequate medical histories/exams, incorrect legal theories or on surmise, speculation, conjecture or guess; (3) Sets forth reasoning behind opinions (not merely conclusions); (4) Discloses familiarity with concept of apportionment, in context of apportionment determinations. Types of reports Comprehensive (first) Follow-up Supplemental Factual correction Type of supplemental report confined to review of the medical records in possession of the QME at the time of the evaluation May be requested in cases involving determination of permanent disability for unrepresented workers Time limits for unavailability of QMEs Injured worker Claims administrator/emploeyer Service of reports - unrepresented workers (permanent impairment, permanent disability, apportionment) Assigned Disability Evaluation Unit office Unrepresented employee Claims administrator/employee Service of reports - psychiatric injury Injured worker directly OR on a designated physician for the purpose of reviewing and discussing the evaluation report with the injured worker Time frame for retention of reports by QME 5 years from the date of report *may retain a signed electronic copy