QME EXAMS 2024 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED ANSWERS BY EXPERTS |, Exams of Nursing

Download QME EXAMS 2024 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED ANSWERS BY EXPERTS | and more Exams Nursing in PDF only on Docsity! 1 | P a g e QME EXAMS 2024 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED ANSWERS BY EXPERTS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+|NEWEST |GUARANTEED PASS |LATEST UPDATE The QME/AME is permitted to talk to whom? A. PTP B. Third party administrator (TPA) C. Defense attorney D. Applicant attorney E. Insurance claims adjuster A. PTP When the PTP writes a permanent and stationary report it is not considered a medical-legal report, unless: A. The worker is not returning to regular work B. The worker is permanent and stationary C. The claim is contested or disputed D. The worker is returning to modified or alternative work E. Future medical care is necessary C. The claim is contested or disputed 'Physician's office' means a bona fide office facility which is identified by a street address and any other more specific designation such as a suite or room number and which contains the usual and customary equipment for the evaluation and treatment appropriate to the physician's medical specialty or practice. Which does not apply? A. Post Office Box B. Parking lot C. Home 2 | P a g e D. Retail store E. All the above E. All the above The injured worker may discontinue the evaluation based on good cause, including: A. Discriminatory conduct toward the worker based on race or sex B. Discriminatory conduct toward the worker based on religion or sexual preference C. Requests for the worker to submit to unnecessary examination or procedure D. Abusive, hostile or rude behavior toward the worker that demonstrates bias E. All the above E. All the above A QME or AME should not: A. Use a PR-3 (PTP, P&S Report - Permanent Disability Report - Pre 2005 injuries) B. Use a PR-4 (PTP, P&S Report - Permanent Impairment Report - Post 2005 injuries) C. Solicit the worker to become a patient D. Make the patient wait more than an hour to be seen E. All of the above E. All of the above The 'QME Appointment Notification Form' should be sent: A. Within 7 business days after scheduling the patient for the evaluation B. Within 5 business days after scheduling the patient for the evaluation C. Within 1 business day after scheduling the patient for the evaluation D. Within 3 business days after scheduling the patient for the evaluation E. Within 10 business days after scheduling the patient for the evaluation B. Within 5 business days after scheduling the patient for the evaluation Which is not true regarding a 2010 injury? A. You need to serve the original QME report within 30 days after examining the patient B. Follow-Up (ML101) report should be served within 30 days after the exam C. Supplemental (ML106) report should be served within 60 days after records received D. A Follow-Up report (ML101) is done within 9 months of the previous examination E. An AME report is allowed to be served within 45 days after seeing the patient E. An AME report is allowed to be served within 45 days after seeing the patient Which of the following statements is not true? A. An aggravation is a new injury B. An exacerbation or flare up is a temporary increase in symptoms 5 | P a g e WPI refers to: A. Whole Permanent Impairment B. With Partial Impairment C. Without Personal Involvement D. Whole Person Impairment E. Whole Person Injury D. Whole Person Impairment 100% total disability is presumed to exist in which of the following injuries? A. Loss of both of the worker's eyes or the sight thereof B. Loss of both of the worker's hands or use thereof C. Practically total paralysis D. A brain injury resulting in incurable mental incapacity or insanity E. All of the above E. All of the above Which of the below statements are false? A. QME panels are picked within geographic region of the worker's home residence B. QMEs are not limited to the number of office locations to evaluate injured workers C. Preference to assigning QME panels is given to unrepresented workers D. QMEs are limited to 10 locations to evaluate injured workers E. A secondary treating physician sends reports to the PTP B. QMEs are not limited to the number of office locations to evaluate injured workers In regard to Supplemental Job Displacement Benefits (SJDB), which are true? A. For injuries before 1-1-13 the voucher amount ranges from $4000 to $10,000 depending upon the permanent disability rating B. For dates of injury on/after 1-1-13 the voucher will be $6000 across the board, regardless of the permanent disability rating C. The voucher will be due 60 days after a treating doctor, AME or QME declares the injured worker permanent and stationary, reports what the worker's work capabilities are and the employer does not offer the worker a job D. If offered, the job must pay no less than 85% of the worker's earnings at the time of the injury, and be expected to last at least 12 months E. All of the Above E. All of the Above The SJDB voucher can be used for? A. Training at a California public school, or other approved provider listed by the state 6 | P a g e B. To pay for licensing or certification and testing fees C. Purchase tools required by a training course D. Up to $1000 to purchase a computer and/or $500 in miscellaneous expenses E. Up to $600 for the services of a licensed placement agency or vocational counselor F. All of the Above F. All of the Above In cases involving physical injury for 1.1.13 dates of injury and forward, injured workers will not be able to collect additional permanent disability for sleep disorders, sexual dysfunction, or psych injuries that did not directly result from those injuries. QME/AMEs and PTPs will not be able to comment on permanent disability add-ons for which conditions, however, can discuss need for treatment: A. Sleep disorders B. Sexual dysfunction C. Psychological issues, unless the physical injury is 'catastrophic,' or where the injured worker was the victim of a violent act or a witness to a violent act/crime D. Pain E. Pain medication F. A, B and C F. A, B and C In which of the settings below must interpreting services, be provided to an injured worker who does not speak or understand English? A. A deposition B. Appeals Board hearing C. Medical-legal examination D. Medical treatment appointment E. All the above E. All the above Which of the below statements is false regarding depositions? A. A physician shall be paid a minimum of 1 hour B. A physician shall be reimbursed at a rate of $250 per hour, or $62.50 per each quarter hour, rounded to the nearest quarter hour C. A physician shall be entitled to reasonable and necessary fees spent related to testimony, reasonable preparation and travel time D. A physician cannot expect compensation for reviewing records E. A physician can bill for time spent reviewing their own records in preparation for the deposition 105. Once an AME, Agreed PQME or PQME has issued a comprehensive medical-legal report and a new medical dispute arises, which of the below statements is true? D. A physician cannot expect compensation for reviewing records 7 | P a g e To the extent possible, the parties shall obtain a follow-up or supplemental evaluation from A. A new evaluator is always used B. Only reports from the PTP are accepted C. A new claim is filed to deal with the new issue D. If not represented, the worker has to get an attorney E. the same evaluator E. the same evaluator The QME shall schedule the initial QME appointment at the office location listed on the QME panel; however, which of the below statements is true? A. The appointment location can be moved to any other office B. The initial appointment location can never be moved; however subsequent evaluations can be done at another office as long as the QME has it listed with the DWC-Medical Unit C. Upon written request D. Only the claims administrator can authorize a move of office locations E. Only a WCAB judge can authorize the move of office locations B. The initial appointment location can never be moved; however subsequent evaluations can be done at another office as long as the QME has it listed with the DWC-Medical Unit A PQME or Agreed PQME who cancels a scheduled appointment shall: A. Reschedule the appointment within 20 calendar days B. Reschedule the appointment within 45 calendar days C. Reschedule the appointment within 15 calendar days D. Reschedule the appointment within 10 calendar days E. Reschedule the appointment within 30 calendar days E. Reschedule the appointment within 30 calendar days In the event that no records are received by the QME/AME to prepare and issue a medical-legal report, which of the following statements are true? A. The QME report must be served within 30 calendar days with or without records B. The QME can wait until the records are received to issue the report C. The QME can contact the treating physician to obtain records D. A, C and E E. The QME should issue a supplemental report when the records are received D. A, C and E The evaluator and employee's treating physician may consult as necessary to produce a complete and accurate report. Which statements below are true? A. The QME/AME evaluator shall note within the report, new or additional information received from 10 | P a g e against the employer, in addition to filing a workers' compensation claim. A. True B. False A. True The Uninsured Employers' Benefit Trust Fund (UEBTF), a special unit within the DWC may pay benefits to injured workers who get injured or ill while working for an illegally uninsured employer. The UEBTF pursues reimbursement of their expenditures from the responsible employer through all available avenues, such as filing a lien against their property. A. True B. False A. True A medical provider network (MPN) is a group of healthcare providers set up by the employer's insurance company and approved by the DWC's administrative director to treat workers injured on the job. A. True B. False A. True The 24 visit cap on chiropractic care, physical therapy and occupational therapy, does not apply to dates of injury before 1-1-04. A. True B. False A. True Temporary Disability payments provided to an injured worker for a date of injury on/after 1-19-04 are limited to 104 weeks. For certain injuries, temporary disability shall not last for more than 240 weeks. Those injuries include: Acute and chronic hepatitis B and C Amputations Severe burns Human immunodeficiency virus (HIV) High-velocity eye injuries Chemical burns to the eyes Pulmonary fibrosis Chronic lung disease. A. True B. False 11 | P a g e A. True The Labor Code (3600) specifically excludes from compensation 7 types of injuries contained in the Physician's Guide. Those include: Injuries caused by the employee's use of alcohol or illegal controlled substances (if it can be shown that the injury would not have occurred otherwise) Intentionally self-inflicted injuries Suicide, if willful and deliberate Injuries resulting from altercations, in which the injured employee is the 'initial physical aggressor' Injuries resulting from the employee's commission of a felony, for which the employee has been convicted Injuries resulting from off-duty recreational activities, where participation in the activities does not constitute part of the employee's work related duties, and where the activity is not an expressed or implicit condition of employment Psychiatric injuries claimed after notice of termination/layoff unless certain conditions exist A. True B. False A. True CC&R 9768.10 indicates that IMR doctors can be an MD, DO or DPM. A. True B. False A. True A 'Secondary Physician' is any physician other than the primary treating physician who examines or provides treatment to the employee, but is not primarily responsible for continuing management of the care of the employee. A. True B. False A. True A medical-legal report shall contain a declaration by the physician signing the report, under penalty of perjury, stating, "I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as to information that I have indicated I received from others. As to that information, I declare under penalty of perjury that the information accurately describes the information provided to me and, except as noted herein, that I believe it to be true." The foregoing declaration shall be dated and signed by the reporting physician and shall indicate the county wherein it was signed. 12 | P a g e A. True B. False A. True A QME who has not paid their recertification fees or let their QME certification lapse, cannot perform a re-evaluation of the patient, however, can perform a supplemental report, where the worker is not examined. A. True B. False A. True A QME may obtain a consultation from any physician as a reasonable and necessary expense. A. True B. False B. False The evaluator and the employee's treating physician(s) may consult as necessary to produce a complete and accurate report. A. True B. False A. True All communications by the parties with the medical-legal evaluator shall be in writing and sent simultaneously to the opposing party when sent to the medical evaluator. A. True B. False A. True Represented parties who have selected an Agreed Medical Evaluator or an Agreed Panel QME shall, as part of their agreement, agree on what information is to be provided to the AME or Agreed PQME. A. True B. False A. True An evaluator shall not request or accept any compensation or thing of value from any source that does or could create a conflict with his or her duties as an evaluator. A. True B. False 15 | P a g e A. True The term impairment in the Guides refers to permanent impairment. A. True B. False A. True The Guides consider both anatomic and functional loss in evaluating impairment. Which of the below is true? A. Anatomic loss refers to damage to an organ system or body structure B. Functional loss refers to a change in function for the organ or body system C. Impairment criteria contained in the Guides provides a standardized method for physicians to use to determine medical impairment D. The impairment criteria in the Guides were developed from scientific evidence and from consensus of chapter authors or of medical specialty societies E. All of the above E. All of the above The evaluating physician needs to ensure that the examinee understands that the evaluation's purpose is assessment and not medical treatment. However, if new diagnoses are discovered, the physician has a medical obligation to inform the requesting party and the employee about the condition and recommend further assessment. A. True B. False A. True The final impairment rating should be rounded to the nearest whole number? A. True B. False A. True For dates of injury before 2005, Subjective Factors of Disability are used to determine intensity and frequency of symptoms/complaints. Which of the below statements are true concerning the frequency of symptoms? A. Constant pain occurs 100% of the time B. Constant pain occurs approximately 90 to 100% of the time C. Frequent pain occurs approximately 75% of the time D. Intermittent pain occurs approximately 50% of the time 16 | P a g e E. Occasional pain occurs approximately 25% of the time F. B, C, D and E F. B, C, D and E For dates of injury before 2005, Subjective Factors of Disability are used to determine intensity and frequency of symptoms/complaints. Which of the below statements are true concerning the intensity of symptoms? A. Severe pain, would preclude the activity precipitating the pain B. Moderate pain can be tolerated, but would cause a marked handicap in the performance of the activity precipitating the pain C. Slight pain can be tolerated but would cause some handicap in the performance of the activity precipitating the pain D. Minimal (or mild) pain would constitute an annoyance, but would cause no handicap in the performance of a particular activity and is non ratable E. All of the above E. All of the above Permanent Disability reports for musculoskeletal injuries for dates of injury before 2005 take into consideration for rating purposes, which of the following? A. Subjective Factors of Disability B. Objective Factors of Disability C. Work Preclusions or Restrictions D. All of the above D. All of the above Permanent Disability reports for psych injuries for dates of injury before 2005 take into consideration Psychiatric Disability Protocols for Work Functions 1 through 8. A. True B. False A. True When a worker is injured and plans to file a claim, which of the following should happen to move the case forward? A. The worker completes a Workers' Compensation Claim Form (DWC 1) questions 1 -8 and the employer contributes to this form, questions 9-17 B. The employer needs to complete an Employer's Report of Occupational Injury or Illness (Form 5020) C. The PTP completes a Doctor's First Report (DFR) of Occupational Injury or Illness (Form 5021) D. All of the above D. All of the above 17 | P a g e While serving as a QME/AME it is not permitted to solicit an injured worker to become your patient. However, if the worker asks you to assume a role as a treating physician, and you accept, you cannot be the QME/AME in the future. A. True B. False A. True A QME must use good clinical judgment in applying the AMA Guides and may utilize any chapter, table or method that most accurately reflects the injured worker's impairment within, "The four corners" of the Guides. (The Guzman Court of Appeals Decision) A. True B. False A. True For psychiatric injuries, impairment is not decided by the AMA Guides, but the Global Assessment of Function (GAF) Scores. A. True B. False A. True A permanent disability/impairment evaluation report cannot be completed if the injured worker's condition is not permanent and stationary/maximum medical improvement. The rating of impairment and apportionment requires P&S/MMI. A. True B. False A. True Which statements below are true? A. A permanent disability report is for a date of injury before 2005 B. A permanent impairment report (AMA) is for a date of injury from 2005 and forward C. Ratings are adjusted for age and occupation D. All the above D. All the above A 1 to 3% add-on rating for pain can only be added if there is a ratable impairment. A. True B. False 20 | P a g e A. True B. False A. True If an interpreter is used in a case, their name and certification number should be listed in the report. A. True B. False A. True Which of the statements below are true about doctors wanting to become QMEs? A. Chiropractors are required to take a 44 Hour California Workers Compensation Evaluation Course or have completed a 300 hour postgraduate specialty program B. A psychologist must have at least 5 years postdoctoral experience in the treatment of emotional or mental disorders C. All physicians must have completed at least a 12 Hour Disability Evaluation Report Writing Program prior to appointment as a QME (Except DCs - 44 Hour Course includes Report Writing) D. Must pass the QME Competency Examination E. All of the above E. All of the above The State of California uses the most current edition of the AMA Guides to determine impairment. A. True B. False - Only the Fifth Edition B. False - Only the Fifth Edition The AMA Guides - Fifth Edition are only used for dates of injury 1-1-05 and forward. A. True B. False A. True A QME/AME may only use 1 chapter of the AMA Guides to provide an impairment rating. A. True B. False - Can use any chapter in the book that is applicable to the injured worker's condition(s) to provide the most accurate rating B. False - Can use any chapter in the book that is applicable to the injured worker's condition(s) to provide the most accurate rating A physician must be a QME to perform medical-legal evaluations and reports. 21 | P a g e A. True B. False - PTPs and AMEs do not have to be a QME to write a medical-legal report B. False - PTPs and AMEs do not have to be a QME to write a medical-legal report An AME must be a QME. A. True B. False B. False Which reports are accepted at the WCAB? A. PTP B. Secondary physician reports, adopted by the PTP C. QME D. AME E. All the above E. All the above A QME must have 6 hours a year, or 12 hours every 2 years of QME continuing education to qualify for reappointment. A. True B. False A. True A QME who has treated the injured worker, must disqualify them self if their name appears on the QME panel list. A. True B. False A. True Any QME who has not paid the QME reappointment fee within 2 years of the due date must retake the QME Competency Examination and pass it prior to regaining or obtaining QME active status. A. True B. False A. True The DWC - Medical Unit is responsible for providing panel QME lists. A. True B. False 22 | P a g e A. True Medical-legal testimony means expert testimony provided by a physician at a deposition or WCAB hearing. A. True B. False A. True Medical research does NOT include reading or reading about the AMA Guides, Treatment Guidelines (i.e. MTUS/ACOEM etc.), the Labor Code, Regulations or other legal materials. A. True B. False A. True An interpreter shall be provided if the injured worker does not proficiently speak or understand the English language. A. True B. False A. True Medical-legal (ML 100 - 106) billing modifiers include. A. -92 Performed by a PTP B. -93 Interpreter needed at the time of the examination (10% more - ML 102 & ML 103) C. -94 Performed by an AME (25% more) D. -95 Performed by a panel QME E. All the above E. All the above A comprehensive medical evaluation and report prepared by the PTP when there are no contested or disputed issues is not considered a medical-legal expense and is billed under the Official Medical Fee Schedule (OMFS) and not the Official Medical-Legal Fee Schedule (OMLFS). A. True B. False A. True Request for Authorization (RFA) is used to request treatment in a work comp claim. A. True B. False 25 | P a g e The five basic categories of workers' compensation benefits are called: A. Medical Treatment, Permanent Disability Benefits, Death Benefit, Supplemental Job Displacement Benefits, Stay-at-Home Stipend. B. Therapeutic Costs Voucher, Temporary Disability Benefits, Permanent Disability Benefits, Death Benefits, Supplemental Job Displacement Benefits. C. Medical Treatment, Temporary Disability Benefits, Permanent Disability Benefits, Death Benefits, Supplemental Job Displacement Benefits. D. Medical Treatment, Temporary Disability Benefits, Permanent Disability Benefits, Death Benefits, Intermediate Benefits, Supplemental Job Displacement Benefits. C. Medical Treatment, Temporary Disability Benefits, Permanent Disability Benefits, Death Benefits, Supplemental Job Displacement Benefits. Temporary Disability Benefits are paid at the rate of ____ and are usually limited by a ____ time cap. A. 2/3 of average weekly wages 2 year B. 90% of average weekly wages 2 year C. 2 /3 of yearly earnings 1 year D. ½ the Bosco rate Seven years A. 2/3 of average weekly wages 2 year Supplemental Job Displacement Benefits are available where: A. Vocational Rehabilitation costs are deemed unreasonable. B. The date of injury is before 1/1/13 and the employer does not offer Return-to Work. C. The injured worker passes the a Job Proficiency Test. D. The date of injury is after 1/1/13 and the employer does not offer Return-to-Work~D. The date of injury is after 1/1/13 and the employer does not offer Return-to-Work Which report, written by an AME, QME, or AQME, does not involve a face-to-face evaluation of an Applicant? A. Initial (aka "Comprehensive") B. Re-evaluation (aka "Follow-up") 26 | P a g e C. Supplemental D. Deposition C. Supplemental In the workers' compensation system, "Injury" is defined as: A. The medical result of an industrial accident B. Acute incident (but not sustained exposure) that causes disability or need for medical treatment. C. Incident or exposure that causes disability or need for medical treatment. D. The medical result of an industrial accident, except those caused by involuntary spasm. C. Incident or exposure that causes disability or need for medical treatment. Exacerbation of prior injury means _____, while aggravation of prior injury means _____. A. There is an increase in symptoms with an increase in PD, and it is considered a new injury There is a temporary increase in symptoms but then a return to baseline causing no additional Permanent Disability (PD). B. The disability rating is increased by 5% The disability rating is increased by 15%. C. There is a temporary increase in symptoms but then a return to baseline causing no additional Permanent Disability (PD) There is an increase in symptoms with an increase in PD, and it is considered a new injury. D. Radiographic progression of the injury New symptoms not previously noted. C. There is a temporary increase in symptoms but then a return to baseline causing no additional Permanent Disability (PD) There is an increase in symptoms with an increase in PD, and it is considered a new injury. Non compensable injuries include those caused by intoxication, injuries that are self~inflicted, injuries resulting from incidents where Applicant is an initial aggressor, injuries sustained while committing a crime, death by suicide, injuries caused by off~duty recreational activities not required by employment, and ______. A. Injuries sustained while at a required company picnic. B. Injuries that were not due to employer negligence. C. Injuries caused by orally ingesting toxins. D. Post-termination psychiatric injuries.~D. Post-termination psychiatric injuries. Non-psychological injuries are considered compensable if ____ of the injury was industrially caused 27 | P a g e Subject to a few exceptions, psychological injuries are considered compensable if ______ of the injury was industrially caused. A. 1 % or more greater than 50% B. 50% or more 75% C. 1 % or more greater than 25% D. 4-6% 95% A. 1 % or more greater than 50% In order to claim psychiatric injury, an employee must have been A. A Peace Officer and injured by a sudden and extraordinary event. B. Employed for at least 6 months, except where psychiatric injury was caused by a "sudden and extraordinary event."Employed for at least 18 months. C. Employed for at least 18 months. D. Subjected to unwanted teasing and nicknames. B. Employed for at least 6 months, except where psychiatric injury was caused by a "sudden and extraordinary event."Employed for at least 18 months. "Permanent Disability" is calculated by: A. QME taking the physician's "impairment rating," and then adjusting based on nature of injury, age, and occupation B. Consulting the AMA guides only C. A special "Rater" taking the physician's "impairment rating," and then adjusting based on nature of injury, age, and occupation D. A QME taking the "impairment rating" and then adjusting for anticipated need for occupational accommodations ( e.g. canes, accessible bathrooms). C. A special "Rater" taking the physician's "impairment rating," and then adjusting based on nature of injury, age, and occupation "Permanent and Stationary" or "P+S" status is achieved when A. The condition has "reached a plateau," meaning that the applicant's condition is well stabilized and unlikely to change substantially in the next year with or without medical treatment. (P & S status may also be referred to as "MMI- Maximal Medical Improvement"). 30 | P a g e C. Disclose the date and location at which the evaluation took place. D. Disclose the true area code of the physician's home phone line. C. Disclose the date and location at which the evaluation took place. Which of the following is included in Regulation 10606 as 1 of 15 items that every QME report should include? A. The Permanent Disability rating B. Apportionment for treatment C. An ergonomic analysis D. Treatment indicated, including past, continuing, and future medical care D. Treatment indicated, including past, continuing, and future medical care QME reports may be read and utilized by: A. Only attorneys within the workers' compensation system. B. Insurance companies/adjuster workers' compensation attorneys non-workers' compensation attorneys involved in 3rd party cases Judges other QMEs/ AM Es treating physicians. C. Only attorneys, insurance adjusters, and judges within the workers' compensation system. D. Those considered to be "ensconced" in the dispute. B. Insurance companies/adjuster workers' compensation attorneys non-workers' compensation attorneys involved in 3rd party cases Judges other QMEs/ AM Es treating physicians. For dates of injury later than ____ either side may request a panel QME or may, but need not, attempt to get _____ A. 1/1/2013 an AME. B. 1/2/05 31 | P a g e the primary treating physician to write the QME report C. 1/1/05 an AME D. 7/5/1989 a Bison report C. 1/1/05 an AME Which of the following is qualified to serve as a QME but may not opine on permanent disability? A. Acupuncturist B. Podiatrist C. Optometrist D. Chiropractor A. Acupuncturist May a QME provide medical treatment within the workers' compensation system? A. No. If a physician serves as a QME, the physician may not also treat within the workers' comp system. B. Yes. A QME may perform treatment services within the workers' comp system and may treat the same individual for whom the physician has done a QME evaluation if the injured worker requests such treatment C. Yes. A QME may perform treatment services within the workers' comp system but may never treat the same individual for whom the physician has done a QME evaluation. D. Yes, but there is an exception for carpal tunnel syndrome. B. Yes. A QME may perform treatment services within the workers' comp system and may treat the same individual for whom the physician has done a QME evaluation if the injured worker requests such treatment Under California Civil Code 56.10, a physician may disclose medical information where it is A. Relevant to a legal claim where the injured worker has placed his or her financial history in issue. B. Requested by only the insurance adjuster. C. Subject to a Schnapps disclosure. D. Relevant to a legal claim where the injured worker has placed his or her-medical history in issue. D. Relevant to a legal claim where the injured worker has placed his or her-medical history in issue. Defense and Applicant sides must each serve _____ to the other party at least 20 days prior to the date of the QME evaluation. A. Only the non-medical records they plan on providing to the QME B. Only the medical records they plan on providing to the QME 32 | P a g e C. All the records they plan on providing to the QME D. A Benson letter C. All the records they plan on providing to the QME Under the regulations, "nonsubstantial matters" like scheduling issues do not constitute ex parte communications for ___ but there is no such rule that applies to _____. A. Treating physicians QMEs B. QME AMEs C. AMEs QMEs D. Acupuncturists physicians C. AMEs QMEs In CA workers' compensation cases, all medical decisions must be based on the _____ standard, which requires medical evidence from a physician. A. Substantial Medical Evidence B. Adequate Medical Evidence C. Preponderance of Medical Evidence D. Irrefutable Medical Evidence A. Substantial Medical Evidence Under Escobedo, a medical opinion must be predicated on _____ must not be speculative must be based on pertinent facts, adequate exam, and history and must set forth the reasoning in support of its conclusions. A. Majority-endorsed medical opinion B. Reasonable Medical Probability C. Scientific Probability D. Benson testimony B. Reasonable Medical Probability The measure for Reasonable Medical Probability is 35 | P a g e A. A work scheduling conflict B. A strongly held belief by the injured worker that he or she is entitled to benefits without the need for an evaluation. C. Physician being thirty minutes late for the evaluation D. Discriminatory conduct by the evaluator based on race, sex, national origin, religion, or sexual preference Abusive, hostile, or rude behavior by the physician and Instances where the evaluator requests the injured worker to submit to unnecessary exams or procedures. D. Discriminatory conduct by the evaluator based on race, sex, national origin, religion, or sexual preference Abusive, hostile, or rude behavior by the physician and Instances where the evaluator requests the injured worker to submit to unnecessary exams or procedures. Under the current system, a QME should consult the A. 4th Edition of the AMA Guides to Impairment B. 5th Edition of the AMA Guides to Impairment C. 6th Edition of the AMA Guides to Impairment B. 5th Edition of the AMA Guides to Impairment Under Almaraz/Guzman analysis, where a strict WPI rating from the AMA Guides does not accurately describe the effects of impairment on an injured worker's functioning, the evaluator: A. Must nonetheless stick to the strict WPI from the applicable table in the AMA Guides. B. May consult only other tables within the same chapter of the AMA guides. C. May consult alternative tables or chapters that the evaluator feels will provide a more accurate rating of the injured worker's impairment. D. May consult only a newer edition of the AMA guides to Impairment C. May consult alternative tables or chapters that the evaluator feels will provide a more accurate rating of the injured worker's impairment. For disability rating, the following are conclusively presumed to be 100% total in character: A. Only the loss of both legs. B. Only the loss of both hands. C. Cauda equina syndrome or upper extremity myelopathy D. Loss of both eyes or the sight thereof Loss of both hands or the use thereof Practically total paralysis 36 | P a g e incurable mental incapacity or insanity. D. Loss of both eyes or the sight thereof Loss of both hands or the use thereof Practically total paralysis incurable mental incapacity or insanity. Under Labor Code 4662, apportionment of permanent disability shall be based on A. An even share of blame spread amongst all previous employers. B. Causation of injury ADE/COE. C. Causation of permanent disability or impairment. D. Length of time at each employment irrespective of job duties C. Causation of permanent disability or impairment. If an applicant has received a prior award of permanent disability: A. It shall be conclusively presumed that the prior permanent disability exists at the time of any subsequent industrial injury. B. It is never relevant for the purposes of a new claim. C. It is presumed (but subject to rebuttal) that the prior permanent disability exists at the time of any subsequent industrial injury. D. It is relevant to job duty accommodations A. It shall be conclusively presumed that the prior permanent disability exists at the time of any subsequent industrial injury. A(n) ____ must be served within 5 business days from setting a QME evaluation date. A. Initial report B. Invoice for anticipated service costs C. Interpreter form with ID and certification number D. Appointment Notification Form D. Appointment Notification Form Only _______ may cancel a QME evaluation due to failure to receive medical record in advance. A. Psychologists and Psychiatrists B. Orthopedists and Chiropractors C. Internal Medicine physicians D. Dentists A. Psychologists and Psychiatrists 37 | P a g e Where an evaluator fills out a Notice of Unavailability for periods of unavailability longer than 14 days, the evaluator may A. Be denied subsequent reappointment if his or her period of unavailability exceeds 30 total days in one year. B. Be denied subsequent reappointment if his or her period of unavailability exceeds 90 total days in one year. C. Be denied subsequent reappointment if his or her period of unavailability exceeds 60 total days in one year. D. Be fined $700 for each unfulfilled panel requested during that time. B. Be denied subsequent reappointment if his or her period of unavailability exceeds 90 total days in one year. A QME certificate must be: A. Saved at the private practice or home office of the QME. B. Be present in a file somewhere at the applicable QME office location. C. Displayed in a conspicuous manner at the applicable office location at all times during the period of QME appointment at that location. D. Displayed on the entry door to the applicable office location at all times that the QME holds a listing there. C. Displayed in a conspicuous manner at the applicable office location at all times during the period of QME appointment at that location. The-direct examination of a medical witness: A. Is usually required at trial in CA Workers' comp cases. B. Is never permitted at trial in CA workers' comp cases. C. Will proceed to trial upon request of the witness. D. Will not be received at trial in CA workers' comp cases except upon a showing of good cause. D. Will not be received at trial in CA workers' comp cases except upon a showing of good cause. A request for extension of time to serve a report must be filed A. At least 20 days prior to the due date. B. At least 15 days prior to the due date. C. At least 5 days prior to the due date. D. Only if the evaluator does not have once square of their schedule to spare within a 14-day span. C. At least 5 days prior to the due date. The required Labor Code §4628 disclosure at the end of every report: A. Is made under penalty of perjury. B. Can be signed by the clerical staff of an evaluator. 40 | P a g e A. Yes B. No B. No If the evaluator determines that the IW's pain increases the burden of the IW's ADLs even slightly, the evaluator may add-on to the IW's impairment how much for pain. A. 0% B. 1%-3% whole person impairment C. No more than 50% of the impairment value already determined D. Up to 3% only if the pain is headache pain B. 1%-3% whole person impairment If an IW has stand-alone headache pain with no other impairment for any other body part or system, the evaluator can do which of the following with regard to an impairment rating: A. No impairment can be given for stand-alone headache pain B. Headache pain can only be rated in the presence of another ratable body part or body system impairment C. A and B D. Headache pain can be given an impairment rating of between 1% to 3% D. Headache pain can be given an impairment rating of between 1% to 3% 'Ex Parte' communication is legally forbidden, unless involving routine matters such as confirming appointments or that records have been sent, etc. The QME or AME should not talk to the attorneys or the carrier. A. True B. False A. True In cases made Permanent & Stationary prior to 01/01/05, the PD (permanent disability) rating is based upon: A. Impairment rating B. Causation C. Subjective factors of disability, objective factors and work restrictions/preclusions D. A & B C. Subjective factors of disability, objective factors and work restrictions/preclusions If an IW's right knee was injured in 2002 and the case was settled with a Stipulated Award and a PD rating of 10% and the IW re-injured the same knee again in 2007 with a PD rating of 20%, which of the following applies with regard to apportionment 41 | P a g e A. If the IW self-rehabilitated after the 2002 injury and had no complaints and was able to do his job without any problems until the 2007 injury occurred, there should be no apportionment. B. Because the 2002 injury was given a PD rating before 2005 and the 2007 same knee was injured after the AMA Guide impairment rating system was established, there should be no apportionment. C. Because the causation for the 2002 right knee injury was different from the causation of the 2007 injury, no apportionment would apply. D. Apportionment applies because it is presumed that a prior PD for the same body part is permanent and still exists. D. Apportionment applies because it is presumed that a prior PD for the same body part is permanent and still exists. In a psyche injury claim, if the QME believes that the IW would be at risk by sending the IW a copy of the QME report with opinions and conclusions about the IW's mental & behavioral status and with regard to mental health records reviewed, the QME should do which of the following? A. Complete a QME 120 Alternative Service form designating another doctor to receive the report and to explain its contents to the IW B. Insist that the IW must retain an attorney, who can then share the report with the IW C. C. Complete a QME Form 121 to protect the disclosure of mental health records D. A & C D. A & C An employee on vacation was asked by his supervisor to take one of the company's clients out to dinner. While doing so, the employee fell and broke her leg. Given this situation, which of the following would best characterize the nature of causation in this case A. COE - The injury occurred during the course of employment B. AOE - The injury arose from employment but did not occur during the course of employment C. AOE/COE - The injury arose from employment and occurred during the course of employment D. There was no industrial causation because the employee was on vacation B. AOE - The injury arose from employment but did not occur during the course of employment An employee was injured in a motor vehicle accident while leaving his job in his car to go home. In this situation causation would be properly interpreted as follows: A. AOE (arose from employment) but not COE (during the course of employment B. COE because this was a daily activity in the normal course of employment C. There was no industrial causation because a normal commute to and from work is not considered to be AOE or COE D. AOE & COE C. There was no industrial causation because a normal commute to and from work is not considered to be AOE or COE 42 | P a g e Cases involving work acquired HIV/AIDS involve confidentiality for the IW that involves: A. Normal medical confidentiality laws B. The mandatory use of the QME 121 Form for protection of records C. The maintenance of a fictitious name file maintained by a WCJ D. A & C D. A & C A QME or AME must address all disputed issues in a claim with the exception of: A. Medical treatment disputes are now done by an IMR B. Causation disputes C. Apportionment disputes D. Impairment rating disputes A. Medical treatment disputes are now done by an IMR Which of the following can a QME or AME not do with regard to the IW being evaluated? A. Request reasonable & necessary diagnostic testing B. Recommend treatment C. Provide treatment on that day, unless it is a medical emergency D. Ask questions regarding the health status of family members C. Provide treatment on that day, unless it is a medical emergency In a situation where a QME has referred the IW out for imaging diagnostics to a radiology group in which the QME's brother-in-law is a partner, which of the following applies? A. The QME is not required to disclose a financial conflict of interest because if it does not involve an immediate family member B. The QME must only disclose a financial conflict of interest if he/she receives direct income from the facility referred to C. The QME is not required to make any disclosures unless a complaint is filed by a party to the case D. The QME must disclose the relationship on a financial conflict of interest form with the AD before proceeding with the referral D. The QME must disclose the relationship on a financial conflict of interest form with the AD before proceeding with the referral A QME must retain QME reports for how many years? A. 5 B. 7 C. 10 D. For as long as the QME maintains his/her QME status 45 | P a g e A QME who uses an assisting nurse to take and record vital signs, a historian to review records and interpret them for the QME, and a clerical worker who transcribes the QME's report has done which of the following: A. Violated medical confidentiality B. Violated under penalty of perjury that the QME reviewed the records; even if the QME uses a historian, the QME needs to also review their work and the records and name them in the report as assisting in the production of the report C. Followed acceptable and legal protocols D. Failed to perform all aspects of the consultation, examination, and report generation without the assistance of others B. Violated under penalty of perjury that the QME reviewed the records; even if the QME uses a historian, the QME needs to also review their work and the records and name them in the report as assisting in the production of the report An Information & Assistance Officer can talk to a represented IW, an unrepresented IW and anyone else. A. True B. False A. True When rating a case made permanent & stationary before 2005, which of the following are used to determine the disability rating? A. Subjective factors of disability (intensity & frequency of pain) B. Objective factors of disability C. Work preclusions/restrictions D. All of the above D. All of the above When measuring extremity joint ranges of motion (ROM) in cases made permanent & stationary prior to 2005, which standard normal values are used? A. AMA Guide to the Evaluation of Permanent Impairment (5th Ed.) B. There are no accepted 'normal' ROM values C. The un-injured extremity ROM is considered to be the 'normal' ROM value D. Packard Thurber's 'Estimated Average Normals' 1960 D. Packard Thurber's 'Estimated Average Normals' 1960 Which of the following are considered to be objective findings? A. Patient complaints which are consistent with examination findings B. Lab tests, electrodiagnostic testing, x-rays and other imaging 46 | P a g e C. Grip strength testing with less than expected effort D. Examination findings that is consistent with the findings of other doctors B. Lab tests, electrodiagnostic testing, x-rays and other imaging Can an IW being evaluated by a QME or AME tape record the consultation and examination? A. Yes B. No A. Yes An IW treating within an approved MPN who does not like or agree with the treating doctor's opinion and treatment plan can do which of the following? A. Seek an opinion from only one other MPN doctor B. Seek an opinion from up to two other doctors within the MPN C. May transfer to the doctor of the IW's choice outside of the MPN D. Must have a hearing at the WCAB to change treating doctors B. Seek an opinion from up to two other doctors within the MPN If an IW is cut on the job, treated on the job with first aid and then sees a doctor for follow up, who returns the IW to work without any restrictions or limitations, the incident should be: A. Filed as a workers' compensation claim B. Reported within 5 days to the DWC-Medical Unit C. Handled only within the employer's/insurance carrier's approved MPN D. Considered a minor first aid incident with no claim filed D. Considered a minor first aid incident with no claim filed An IW who had fractured her fibula in a fall on steps at work was provided with appropriate treatment and rehabilitation, eventually being returned to work with no job-limiting preclusions/restrictions. When finally evaluated, it was determined that her routine ADLs were not affected, and there were no positive examination findings but the evaluating QME gave her a 3% rating for pain. Which of the following would be true? A. Residual pain/discomfort, irrespective of the ADLs, can be given between a 1%-3% WPI rating B. An impairment rating for pain is only valid if the IW is reasonably required to take pain medication C. No impairment rating should have been given for pain with a 0% rating D. Fibula fracture, irrespective of treatment outcome, carries an automatic impairment rating forreasonably anticipated post-surgical pain involvement C. No impairment rating should have been given for pain with a 0% rating When evaluating an injured extremity in a 2010 case, the evaluator must do which of the following? 47 | P a g e A. Compare findings to normal values in the AMA Guide (5th Ed.) B. Compare findings to Packard Thurber's 'Estimate Average Normals' C. Compare findings to the opposite, un-injured extremity D. Report only findings relevant to the injured extremity A. Compare findings to normal values in the AMA Guide (5th Ed.) 43. When evaluating an IW with impairment to three separate body parts, (e.g., elbow, low back, and knee), how should the impairment values for each body party be handled to establish an overall combined whole body impairment rating? A. The values for each body part should be combined using the Combined Values Chart (Page 604) in the AMA Guide (5th Ed.) starting with the highest value (Yes, per the AMA Guides - but not the state of CA, which wants you to bring each body part to a whole person impairment rating and leave it alone) B. The values for each body part should be added together C. The values for each body part should be listed separately and not added or combined D. The values should only be combined if the different body part impairments were caused by the sameinjury A. The values for each body part should be combined using the Combined Values Chart (Page 604) in the AMA Guide (5th Ed.) starting with the highest value (Yes, per the AMA Guides - but not the state of CA, which wants you to bring each body part to a whole person impairment rating and leave it alone) An IW who is being accommodated by their employer with modified work duty should receive temporary disability compensation only if the following is true: A. Only if the modified work pays less than 85% of the IW's salary/earnings that were being paidat the time of the injury B. Only if the IW is a medically eligible qualified injured worker C. Only if the IW has been given a final impairment or disability rating D. Only if the modified work pays less than 90% of the IW's salary/earnings that were being paid at thetime of the injury A. Only if the modified work pays less than 85% of the IW's salary/earnings that were being paidat the time of the injury If a licensed doctor is not a QME but both parties in a represented case, (both attorneys), agree to use the doctor as an AME to perform a medical-legal evaluation to resolve a disputed issue, it is legally permissible. A. True B. False A. True If a person reviews the records for a QME for purposes of organizing and consolidating the records, it is considered: 50 | P a g e Which of the following is not a benefit guaranteed by the workers' compensation system in California? A. Cost of living expenses B. Medical Treatment C. Temporary disability benefits D. Supplemental job displacement benefits E. Death benefits A. Cost of living expenses If any IW self-procures an evaluation from a doctor who is not the PTP or the QME, which of the following is true? A. Only the PTP must issue a supplemental report commenting on the self-procured report B. The PTP or the QME must issue a supplemental report commenting on the self-procured report C. Only the QME is required to issue a supplemental report commenting on the self-procured report D. The self-procured report is inadmissible E. B & D E. B & D In a psych claim, the burden of proof is on the IW to prove that at least what percent of the psychological injury was caused by work? A. 25% or greater B. 51% or greater C. 75% or greater D. There is no minimum threshold for causation in a psyche claim B. 51% or greater If an evaluator bases an opinion or conclusion on reasonable medical 'probability', it means that the probability is? A. 26% or greater B. 51% or greater C. 90% or greater D. 100% B. 51% or greater In a case involving a low back injury, the QME concluded that 50% of the IW's impairment should be apportioned to minimal degenerative disc disease (DDD) which appears on pre-injury x-rays. The QME opined that at least 50% of the IW's impairment/disability would have resulted in the future anyway absent the industrial injury. The IW objected because she said that she had no pre-injury complaints and no pre-injury need for professional or self-treatment and because there were no formally imposed or self-imposed activity/work limitations before the industrial injury and that she could perform all of her ADLs without a problem pre-injury. In this case, which of the following best describes the QME's 51 | P a g e conclusion? A. It was correct because under LC4663 there can be apportionment to pre-existing pathology B. It was correct because the pre-existing degenerative disease contributed to the IW's post-injury impairment C. It wa D. It was incorrect because you can only apportion to the cause of disability/impairment and because it is speculation to assume the onset of impairment at some unknown, non-specific time in the future unless the pathology involved has a scientifically established progression, and the DDD is minimal In a claim involving a convenience store hold-up where the employee was physically injured, the IW also claimed psychological injury. Given this situation, which of the following is the most correct answer? A. A compensable psych injury is treatable but not ratable B. If a psych injury claim is the result of experiencing or witnessing a violent act, it is both treatable and ratable C. If a psych injury claim is the result of experiencing or witnessing a violent act and it can be proved that at least 35% of the psych injury resulted from violence experienced or witnessed on the job, it is both treatable and ratable D. Only the person committing the violent act can be sued civilly and no work comp claim can be filed C. If a psych injury claim is the result of experiencing or witnessing a violent act and it can be proved that at least 35% of the psych injury resulted from violence experienced or witnessed on the job, it is both treatable and ratable A Request for Authorization (RFA) for treatment can legally be denied by the employer's/insurance carrier's Utilization Review doctor if the treatment is not consistent with which of the following? A. MTUS B. Standard of practice C. ACOEM D. A & C D. A & C A QME concluded that a claimed injury involving an employee's knee was non-industrial and therefore non-compensable because the claimant's knee had significant impairment/disability before the industrial injury occurred. The injured worker/claimant objected because she said that her level of impairment/disability had been aggravated and was now worse because of the industrial injury. Which of the following is the most correct? A. If a true aggravation has occurred, it means that there is new and/or further impairment/disability and, therefore, a claim is legally justified B. If there is as little as 1% of the impairment/disability resulting from an industrial injury, it is considered to be a compensable claim C. If there is pre-existing impairment/disability, it must not exceed the post-injury level of 52 | P a g e impairment/disability by more than 50% for the claim to be compensable D. A & B D. A & B Post-termination, an employee filed a claim because he said that his termination caused him psychological harm and stress, and he demonstrated that more than 51% of his stress was caused by the termination action. Which is correct? A. Having met the 51% or greater threshold for causation, the claim is compensable B. In a post-termination stress claim, the IW must prove greater than 75% causation related to the termination action C. Psychological injury claims based upon stress are no longer compensable since the passage of SB863 D. In a 'good faith personnel action', there is no legal basis for a psych claim; however, if the employer purposefully embarrassed the employee in front of other people, ridiculed, made fun of, or threatened them, etc. the employer may have issues D. In a 'good faith personnel action', there is no legal basis for a psych claim; however, if the employer purposefully embarrassed the employee in front of other people, ridiculed, made fun of, or threatened them, etc. the employer may have issues In a represented case, both attorneys received the same QME panel list with three QMEs listed on it in the specialty requested. Both attorneys agreed to the same QME from list, therefore: A. The panel QME was agreed to and can charge 25% more for their QME services B. Because the evaluator is a panel QME and not an AME, the QME cannot charge any additional amount over and above the normal ML code charges C. The panel QME cannot be considered to be agreed upon unless two of the other names on the list were stricken by the attorneys D. The panel QME's charge is not bound by the Official Medical Legal Fee Schedule because the QME was agreed to. A. The panel QME was agreed to and can charge 25% more for their QME services In 2008 a workers' compensation claim with a Date of Injury (DOI) in 2001 was re-evaluated and the IW was finally found by the QME to be permanent & stationary for purposes of providing a final rating. Given the DOI, which of the following is most correct and applicable in this situation? A. Under SB899, all cases made permanent & stationary after 2005 are rated using the AMA Guide (5th Ed.) impairment rating system B. Under SB899, only cases with a DOI of 01/01/05 forward can be rated using the AMA Guide (5th Ed.) C. IWs with a DOI before 2005 but made permanent & stationary from 01/01/05 forward should be rated with the system that provides the highest disability rating D. None of the above is correct. 55 | P a g e Medical-legal expense means any costs or expenses incurred to: A. Confer with the worker's family B. Prove or disprove a contested claim C. Confer with a secondary physician D. Review a job description E. Initiate a treatment plan B. Prove or disprove a contested claim A Supplemental Medical-legal Report (ML 106) involves the following: A. Does not involve examination of the injured worker B. Reviewing records/test results, sub rosa video, etc. not previously available C. Preparing a narrative report, performed by a QME/AME/PTP D. Must be served within 60 days E. All of the above E. All of the above A Follow Up Medical-Legal Report (ML 101) involves the following: A. A re-examination of the injured worker B. May involve reviewing records/test results, sub rosa video, not previously available C. Preparing a narrative report, performed by a QME/AME/PTP D. Is done within 9 months of the prior evaluation, and is served within 30 days E. All of the above E. All of the above Ex Parte communication of the QME or AME is permitted when? A. Never B. Only after the ML report is sent C. Only after the claim is denied D. Only after the claim is accepted E. After the worker is permanent and stationary A. Never 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 56 | P a g e (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 (1) Compensability of the claim; (2) Permanent disability; (3) "Catch-all" (temporary disability, work restrictions, new and further disabilities after permanent disability (detereoration of original injury), compensability of new body part added to claim) Definition of injury in compensability claims (1) An injury or disease arising out of employment; (2) A derivative injury caused by treatment of an injury arising out of employment; (3) Any reaction to or side effect from preventative health care the employer provides to health care workers Specific injury Occurs as the result of a single incident or exposure Cumulative injury Results from repetitive trauma (mental or physical) over a period of time 2 requirements for a condition to be considered an injury (1) Cause disability; or (2) Result in a need for medical treatment Occupational disease Disease that in whole or part is caused by work 57 | P a g e 7 types of excluded injuries (1) Caused by employee's use of alcohol or illegal controlled substances; (2) Intentionally self-inflicted injuries; (3) Suicide; (4) Resulting from altercations, in which the injured employee is the initial physical aggressor; (5) Resulting from the employee's commission of a felony, for which the employee has been convicted (including "wobbly felonies," which are crimes that may be prosecuted as misdemeanors or felonies) (6) Resulting from off-duty recreational activities, in which participation in the activities does not 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 60 | P a g e 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**) Right to invoke evaluation of permanent disability Injured worker OR Claims administrator Trigger for permanent disability dispute Termination of temporary disability by treating physician (via report) Cause for termination of temporary disability Finding of permanent and stationary (P&S) OR maximum medical improvement (MMI) by the primary treating physician Only admissible reports before a WCJ on the issue of permanent disability QME report Evaluation(s) prepared by treating physician(s) Apportionment Estimate of approximate percentage of permanent disability caused by a work-related injury (& approximate percentage caused by other factors) Only applies to permanent disability Regions of the body (1) Hearing (2) Vision (3) Mental and behavioral disorders (4) Spine 61 | P a g e (5) Upper extremities, including shoulders (6) Lower extremities, including hip joints (7) Head (8) Face (9) CV system (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 62 | P a g e 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 Employee (+ representative) Employer/claims administrator (+ representative) Trigger to send medical records and other information to the QME Receipt of the QME Appointment Notification Form Causes for issuance of a replacement panel (1) Failure to serve the QME Appointment Notification Form; (2) Disclosure of COI by an evaluator after an appointment has been made; (3) Necessity for subsequent examination by a QME in a different specialty (due to limitations in scope of practice or clinical competency) (4) QME doesn't practice in the requested specialty (5) QME cannot schedule an appointment within 60 days of the initial request of the appointment (6) Injured worker changes address since initial request for a panel but before initial appointment (7) Two or more members of a QME panel are from the same group practice (8) QME is unavailabile (9) QME who previously reported on the case is unavailable (10) QME is currently, or has been, the treating physician of the worker for the injury currently under dispute (11) Claims administrator/employer agrees that a new panel be issued based upon the geographic area of the worker's employment (12) Untimely filing of report by QME 65 | P a g e (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 66 | P a g e 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 14-90 days Time frame in which QMEs must notify medical director of unavailability At least 30 days before the period of unavailability is to begin Good cause for periods of unavailability longer than 90 days during the QME calendar year Sabbaticals Death/serious illness of an immediate family member Time limit for an initial or follow-up comprehensive medical-legal evaluation 30 days after the evaluation Extension: no more than 30 days Time limit to complete and serve a supplemental report 60 days after date of a written/electronic request to the QME Extension: no more than 30 days Time frame to review corrections and determine if factual corrections are necessary 10 days after service of Request for Factual Correction, if filed by the injured worker 15 days after service, if filed by the claims administrator or by both parties Service of reports - represented workers (comprehensive, follow-up, or supplemental reports) 67 | P a g e Injured worker + attorney Claims administrator/employer Service of reports - unrepresented workers (comprehensive, follow-up, or supplemental reports) 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 1911, SEVENTEEN DAYS AFTER THE DEVISTATING FIRE AT THE TRIANGLE SHIRTWAIST COMPANY FACTORY IN NEW YORK TOOK 146 LIVES when was the 1st work comp act passed? 1. NO FAULT 2. EXCLUSIVE REMEDY 3. ASSURED FIXED BENEFIT WHAT ARE THE 3 COMPONENTS OF THE WORK COMP SYSTEM e employer is required to pay benefits no matter who caused the injury, as long as the injury arose out of or occurred in the course of employment. NO FAULT less the employer is uninsured, the worker cannot pursue other forms of recovery from the employer, even if the employer was grossly negligent. EXCLUSIVE REMEDY The workers' compensation system establishes defined benefits, which must be paid for by the employer. Workers' compensation awards are typically far less than comparable negligence awards in a civil suit. For example, although the maximum workers' compensation death benefit may be far less than the possible award in a civil wrongful death suit, a civil action may take years to resolve while a 70 | P a g e An employer must provide compensation, without regard to negligence, for "any injury sustained by his or her employees arising out of and in the course of the employment." What Is a Compensable Injury? • There must be an "injury" (physiological or psychological harm). • There must be an employment relationship. • The injury must have been caused by the employment. • The injury must occur in the course of the employment (COE), that is, at the time of the inju-ry, the employee must have been performing a service that grew out of and was incidental to the employment. What are the Four basic condi-tions must be met for a workers' compensation claim to be established: COE COURSE OF EMPLOYMENT What Is Considered an Aggravation of a Pre-Existing Non-Industrial Condition? AOE ARRISING OUT OF EMPLOYMENT What Is Considered an Aggravation of a Pre-Existing Non-Industrial Condition? a worker who suffers an on-the-job aggravation of a non-industrial pre-existing disease or underlying condition has sustained a new injury. Symptoms that are from a "flare-up" or "recurrence" of a previous industrial injury or illness, but have not been caused by the current employment do not constitute a new injury. WHEN AN OLD INJURY IS NOT CAUSED BY EMPLOYEMENT -In a specific injury, the DOI is simply the date on which the incident or exposure occurred -In a cumulative injury or occupational illness, the DOI is the 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 What Is the "Date of Injury" • The statute of limitations for particular procedures within the workers' compensation sys-tem • The regulations that will apply to the worker's injury • The compensation rate for the worker's injury • The employers who are liable for the claim. The DOI is important because it determines: • To file a workers' compensation claim • To file a claim with the appeals board. Important time limits controlled by the DOI include how long a worker has: Is the Injury Work-Related (AOE/COE)? 71 | P a g e All that is required is proof of a reasonable medical probability. 1. What pathological condition(s) (and disability) are present? 2. What relevant work exposures were present? 3. What other causes might produce the disease (i.e., non-industrial exposures WHAT 3 FACTORS NEED TO BE ESTABLISHED IN ORDER TO MAKE A CAUSATION DETERMINATION? 1.Direct Causation: The work exposures are directly responsible for the health outcomes. 2.Contributing Cause: Several factors led to the disease; work exposure is one of these factors. 3.Acceleration: The disease process is accelerated by virtue of work exposure. The date of the onset of the disease is much sooner than it would have been in the absence of the exposure. 4.Precipitation: The 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. 5.Aggravation: A medical condition may be present already, but work exposure makes it worse. What are the five major types of causation: a workers' compensation judge In a contested case, who will decide evidence on AOE and COE in the determination of compensability firefighters, forestry officers, peace officers, and correctional employees. conditions that mani-fest or develop during the period of active service and following termination of service for up to five years specific conditions (e.g. hernias, pneumonia, tuberculosis, heart disease, and can-cer) as work related when they affect which certain employees? it is a diagnosed mental disorder that causes disability or need for medical treat-ment, and the employee can demonstrate that the events of employment were the "predominant cause" of the injury. A psychiatric injury is compensable if psychiatric injuries and claims filed after notice of termination or layoff/termination are not compensable unless the actual events of employment were the predom-inant cause and any of the following conditions are met: • The injury was the result of sudden and extraordinary events of employment. • The employer had notice of the injury before the notice of termination or layoff. • Medical records existing before the notice of termination or layoff contain evidence of treatment of the psychiatric injury. • A contractual, administrative, regulatory, or judicial trier of fact (judge, referee, or other individual who hears and makes decisions on a case) has found that there was sexual or racial harassment. • There is evidence that the DOI is subsequent to the date of notice of termination, but before the effective date of the termination. This provision allows post-termination claims for cu-mulative injuries or occupational illnesses that do not manifest themselves until after the employee has left the job. What Happens If a psychiatric Claim Is Filed after Notice of Termination or Layoff? 72 | P a g e To receive compensation, an employee who sustains a work-related specific injury, occupational illness, or cumulative trauma must inform the employer about the injury or illness within 30 days of the date of injury. how long does an employee have to report a work leaked injury? how long does an employer have after notified of a disability The employer must furnish the employee with an Employee's Claim for Work-ers' Compensation Benefits (DWC 1) claim form within one working day of learning of the injury. • Provide a safe and healthful workplace for their employees • Carry insurance to meet their obligations under workers' compensation law or to provide the DIR with proof of self-insurance • Provide information about workers' compensation to their employees, including infor-mation on where and how to file a claim and on how to predesignate a personal physician • Maintain records of occupational injuries and diseases • Report immediately to the Division of Occupational Safety and Health (DOSH), better known as Cal/OSHA, any death or serious injury. • Provide the claim form (DWC 1) within one working day of the employer's knowledge of the injury • Complete an Employer's Report of Occupational Injury or Illness ("Employer's First Report" Form 5020), within five days of being notified by the employee of an occupational injury or illness. Employers are obligated to: A serious injury is defined as an injury that results in more than 24 hours of hospitalization for something other than observation, loss of a body part, or any serious degree of disfigurement. serious injury definition • Discriminating against workers for their health and safety activities or for filing a workers' compensation claim • Terminating an injured worker during the period of temporary disability, unless the em-ployer can prove that the termination was due to a "business necessity" • an employer cannot refuse to reinstate an injured worker, unless the worker can no longer perform the essential functions of the job or based on a medical opinion that pro-vides reasonable fear of re- injury. Employers are prohibited from: Insurance Carriers and Claims Administrators role providing a communication conduit be-tween the parties Employers have an obligation to authorize medical treat-ment up to $10,000 within one working day after the claim is filed. how much medical treatment can be auth in one day after claim filed? • Temporary disability is not paid to injured workers for the first three days of missed work unless they are hospitalized or miss more than 14 days of work. 75 | P a g e (6) Off-duty recreational activities (7) Psychiatric injuries claimed after notice of termination What are the 4 basic conditions to establish a workers' compensation claim? (1) Injury (2) Employment relationship (3) Injury caused by the employment (AOE) (4) Occurred in the course of the employment (COE) What 3 requirements constitutes an aggravation of a pre-existing, non-industrial condition in WC cases? (1) Causes a temporary or permanent increase in disability (2) Creates a new need for medical treatment (3) Requires a change in the existing course of treatment What 4 items are determined by the DOI? (1) Compensation rate (2) Employers who are liable for the claim. (3) Statute of limitations for particular procedures (4) Regulations that will apply to the worker's injury What are 3 factors are needed to establish a causation determination? (1) Presence of pathological conditions and disability (2) Relevant work exposures (3) Non-industrial exposures (other causes of disease) What are the 5 major types of causation? (1) Direct (2) Contributing (3) Acceleration (4) Precipitation (5) Aggravation What is the definition of direct causation? Work exposures are directly responsible for the health outcomes What is the definition of contributing causation? Several work factors led to the disease What is the definition of Acceleration Causation? - Disease/injury is accelerated by of work. - (The date of the onset of the disease is much sooner than it would have been in the absence of the exposure) What is the definition of precipitation causation? 76 | P a g e - Work exposure causes the the illness. (For example, an underlying tendency or asymptomatic problem was present, but the work exposure causes it to clinically manifest.) What is the definition of Aggravation Causation? A medical condition may be present already, but work exposure makes it worse What is principle of "taking employees as you find them"? The employer cannot avoid liability for an occupational 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. What are the 3 criteria for compensation of psychiatric injuries in WC claims? (1) Diagnosed mental disorder (2) Causes disability or need for medical treatment (3) Employee can demonstrate that events of employment were predominant cause of the injury What is the definition of proximate cause? Connection between injury and employment *Employment does not need to be the only cause of injury, just a contributing cause What are the 5 requirements needed to constitute a psychiatric injury in WC claims? (1) Actual events of employment were the predominant cause > 50% among all combined causes of the psychiatric injury (except if the injury is a derivative of an underlying physical injury) (2) If the injury resulted from a violent act (contributed >= 35% causation) (3) worked for at least 6 months (not continuously), unless the injury was caused by a sudden and extraordinary employment condition (4) Injury was not substantially caused by "lawful, nondiscriminatory, good faith personnel actions" - 35% to more. (e.g., being passed over for promotion or being transferred to another department) (5) Claim can not be filed after notification of termination or layoff What are 5 criteria for compensation 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) Psychiatric Medical records existing before the notice of termination/layoff (4) Sexual or racial harassment. (5) There is evidence that the DOI is after the date of notice of termination, but before the effective date of the termination. Who determines IW Impairment ratings? A QME/PTP/AME 77 | P a g e Who has the responsibility of assigning the permanent disability rating? The Disability Evaluation Unit (not physicians) What can cause a Permanent Disability dispute? The termination of Temporary Disability by treating physician What is the cause for termination of Temporary Disability benefits? The finding of P&S / MMI by the primary treating physician. What is Apportionment? Estimate of approximate percentage of permanent disability caused by a work-related injury and approximate percentage caused by non work-related injuries. Apportionment only applies to Permanent Disability. What regions of the body are evaluated by QME/AME for Impairment Ratings? (1) Hearing (2) Vision (3) Mental and behavioral disorders (4) Spine (5) Upper extremities, including shoulders (6) Lower extremities, including hip joints (7) Head (8) Face (9) CV system (10) Respiratory system (11) All other systems/regions What 4 injuries would automatically give an IW a 100% PD rating? (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 What is the definition of "Impairment" in WC claims? Amputation of, loss of use of, or derangement of any body part, organ system or organ function. Ex: losing a finger or ability to speak What is the definition of "Disability" in WC claims? Alteration of an individual's capacity to meet personal, social, or occupational demands or statutory or regulatory requirements because of an Impairment. Ex: Inability to type (Disability) due to loss of hand (Impairment). 80 | P a g e What are 3 examples/situations that constitute good cause for discontinuing a comprehensive medical- legal evaluation by a QME? (1) IW uses abusive language (2) IW deliberately attempts to disrupt the evaluation (3) IW is intoxicated or under the influence of any medication What is the minimum face-to-face time requirements for uncomplicated evaluations? 20 minutes for neuromusculoskeletal evaluations 30 minutes for all other evaluations 60 minutes for psychiatric evaluations What are the 4 standards for determining if a report has substantial evidence? (1) Reasonable medical probability (2) Not based on inadequate medical histories/exams, incorrect legal theories or on surmise, speculation, conjecture or guess (3) Reasoning behind opinions (not merely conclusions) (4) Discloses familiarity with concept of apportionment How many days can a QME be unavailable to perform evaluations? 14-90 days How many days does a QME have to notify the medical director of their unavailability? 30 days before unavailability begins How many days does a QME have to submit an initial medical-legal evaluation? 30 days after the evaluation How many days does a QME have to submit a supplemental report? 60 days How many days does the evaluator have to review corrections and determine if factual corrections are necessary? 10 days after service of Request for Factual Correction, if filed by the injured worker 15 days after service, if filed by the claims administrator or by both parties How long must a QME keep evaluation records for? 5 years from the date of report Secondary erectile dysfunction, sleep disorders, and/or psych disorders that are a compensable consequence of the primary injury for injuries on or after 01/01/2013 are...? treatable under the claim but not ratable to disability or impairment (unless it is catastrophic in nature) 81 | P a g e Which specialty is prohibited from writing a medical legal report in a case where impairment and disability are being disputed? Acupuncture (haha losers) A QME report is due _____ days after the completion of the face-to-face evaluation 30 days A Supplemental QME report (no face-to-face evaluation) is due _____ days after the QME received a request to do the report? 60 days In cases made permanent and stationary before January 1, 2005 the permanent disability rating is based upon which three things? 1. Subjective factors of disability 2. Objective factors 3. Work restrictions Apportionment can only be based on what? Causation of the Permanent Disability What is not a routine Activity of Daily Living per the AMA guide to the evaluation of permanent impairment 5th Ed? Ability to work How long are Temporary Disability Benefits and payments made from 2005 and on? 104 weeks When measuring extremity joint ranges of motion in cases made Permanent and Stationary before 2005, which standard normal value guide is used? Packard Thurber's "Estimated Average Normals" 1960 (after 2005 = AMA Guidelines 5th) An injured worker being treated within an approved MPN who does not agree with the treating doctors opinion and treatment plan can seek opinions from how many other doctors within the employers MPN? 2 other doctors within the MPN True or false, and impairment rating of up to 3% for pain can be given to a worker that does not have any other impairment (0%) False An injured worker who is being accommodated by their employer with modified work duty should receive temporary disability compensation only if what is true? Only if the modified work pays less than 85% of the IW's salary that was being paid at the time of injury 82 | P a g e True or false, if a licensed doctor is not a QME but both attorneys in a represented case agree to use the doctor as an AME to perform in medical legal evaluation to resolve a dispute it issue, it is legally permissible. True If a QME has previously treated the injured worker scheduled to be evaluated, can the QME legally proceed to evaluate the worker without a conflict of interest? Nope When a QME completes a report in an unrepresented case where the injured worker is found to be P&S and has been given a final impairment rating, who must the report be sent to (besides the IW and the insurance carrier)? Disability Evaluation Unit (DEU) In an unrepresented case, if the DEU has not issued a summary rating determination, can the QME's send out a supplemental report? No, supplemental report should not be issued until a determination is made by the DEU If an AME or an agreed panel QME is used to evaluate a case, how much more can the AME/PQME charge to the amount for their medical legal services? 25% more than the regular medical legal charge Which benefit is not guaranteed by the Worker's Compensation system in California? Cost of living expenses If an injured worker self obtains an evaluation from a doctor who is not the PTP or the QME, what must the PTP/QME do? They must issue a supplemental report commenting on the self obtain report and the self obtained report is inadmissible An RFA for treatment can legally be denied by the employer's insurance carriers Utilization Review doctor if the treatment is not consistent with which two things? 1. MTUS 2. ACOEM What impairment rating system is used for all cases that are permanent and stationary starting 01/01/2005? AMA Guide 5th Ed. Temporary disability benefits (TDB) normally cannot be paid the longer than 104 weeks unless the injury involves what? 1. Psychosis resulting from violence 2. Severe burns 85 | P a g e True True or false: In the AMA guides, in situation where impairment ratings are not provided for a particular condition, an analogy to a similar condition should be provided? True True or false: Up to 3% whole person impairment may be increased for the effects of treatment or lack of treatment (medication)? True Which method is used to apportion PD? The subtraction method "Any person who knowingly presents a false claim for the payment of a loss, is guilty of a crime and may be for up to ______ years or a fine up to $______, or both" 5 years, $50,000 For injuries on or after 01/01/1994 and before 01/01/2004, IW will be limited to a $_____ maximum on Vocational Rehabilitation benefits under that plan? $16,000 What unit receives complaints for late benefit payment and medical payments? Audit and Enforcement Unit How many days from the DOI does an IW have to inform their employer about the injury/illness? 30 days What is the "unreasonably unpaid" penalty (%) when payment for treatment is not paid as required? 10% increase What does "En Banc" mean? to hear the case as a whole Who calls the QME, in an unrepresented case, to make the first appointment? The patient With a DOI before 1994, the QME must submit the evaluation report within _____ days of the evaluation? 45 days (after 1994 30 days) What is the difference between light duty and modified duty, both of which are "reasonable accommodations" 86 | P a g e - Light duty = totally different job - Modified duty = same job modified Subjective, objective, and work exclusions are considered for disability rating for cases that have an established ____ date before 2005 DOI (not P&S) Packard Thurber's ROM is used for cases that have an established ____ date before 2005 P&S (not DOI) determination Where are QME reports from unrepresented cases sent to? DEU Supplemental reports in unrepresented cases should not be sent to DEU until _____ has been issued? Summary Rating Determination (SRD) What does the medical modifier -92 indicate? PTP What does the medical modifier -93 indicate? Interpreter What does the medical modifier -94 indicate? AME or APQME What does the medical modifier -95 indicate? Panel QME A PQME or APQME (but not AME) must reschedule cancelled appointments within ____ days? 30 days to reschedule Can an initial QME appointments be moved to a different location? No, but the following appointments can be scheduled at another location Starting date of ______, physical injury cases, sleep, sex, and psych impairments are not ratable without direct cause; however they can still be treated for them? 01/01/2013 What are the SJDB amounts for DOI after 01/01/2013? $6,000 What are the SJDB amounts for DOI before 01/01/2013? $4,000- $10,000 87 | P a g e PQME's are picked based on whose physical address? Injured Worker's home address How long does the PTP have to submit DFR? 5 days to submit DFR Who appoints disciplinary actions against QME's? Administrative Director How long does an IW have to dispute a claim? 10 days If a QME is deposed, how many days do they have to make an appointment? 120 days (4 months) How long does an unrepresented employees have to select from a PQME? 10 days How many days before being unavailable must a QME submit a Notice of Unavailability (Form 109)? 30 days before being unavailable (for 14-90 days of unavailability) What are the two exceptions to using the AMA Guides 5th Ed. to the evaluation of permanent impairment in terms of 1) Type of cases? and 2) Case dates? 1) Psychiatric cases 2) Cases prior to 1/1/2005 What are the two exceptions to the requirement that QMEs have 1/3 of their time devoted to direct clinical practice? 1) QME has been an AME 8 times or more in the past year 2) QME is retired or a teaching physician What are the limitations to apportionment? 1) Apportionment applies only to the causation of PD; cannot be applied to treatment, work restrictions, etc. What are the five major categories of QME disciplinary action? 1) Consistent late reports 2) Lack of availability 3) Ex-Parte communications 4) Self referral 5) Reports do not meet DWC minimum standards What must be included with the HPI? 90 | P a g e Which DWC unit receives complaints against adjustors? Audit Unit What are disability determinations based on? PRDS - permanent disability rating schedule Which state appointed body studies and makes recommendations to improve California workers compensation system? Commission of Health and Safety and Workers Compensation (CHSWC) What form is filled out by the employee and insurance carrier to determine Return To Work (RTW)? RU-91 (description of employees job duties) What form is used to request a hearing in front of an administrative law judge when ready to resolve a dispute? Declaration Of Readiness (DOR) Whenever report is written in whole or part by physician other than the examiner, it is considered? Consultation The employer must pay for medical treatment of any non-industrial condition that prevents what? Full implementation of needed medical care for the industrial injury Prophylactic work restrictions are designed to do what? Protect the injured worker from sustaining any further injury True or False, it is appropriate for a QME to determine that two injuries cannot be apportioned because the injuries are "inextricably intertwined"? True Which party designates the specialty of a QME panel? The submitting party When are supplemental job displacement benefits SJDB given? When the employer does not offer Return-to-Work (After 1/1/13) A _____ day extension will be given when asked by a QME waiting for test results or reports 30 day extension A _____ day extension will be given when asked by a QME with "Good Cause" (natural disaster or medical emergency) 15 day extension 91 | P a g e How many days before the examination does each party have to submit all the records to the QME? 20 days before the examination A QME does not have to provide a copy of the psychiatric report to an injured worker when? the report may cause harm to the IW What 2 doctor specialties may cancel a QME evaluation due to failure to receive medical records in advance? Psychologists and Psychiatrists Request for an extension to serve a report must be filed _____ days before the due date? 5 days before the due date Supplemental reports must been completed and served within _____ days of the exam 60 days of the exam Who decides if an injury occurred during Course of Employment (COE)? WCAB or Judge Psychiatric injuries caused from violent act must have been contributed to at least _____ percent of the total injury causation? 35% What is the maximum amount of supplemental job displacement benefits vouchers for DOI after 01/01/2013 $6,000 For DOI after 01/01/2013, reasonable burial expenses are not to exceed _____ dollars? $10,000 For cases covered by an MPN, if there continues to be a disagreement after the 2nd and 3rd opinions, an injured worker may request what? A new PTP Progress reports (PR-2) must be filed every _____ days and or within _____ days before an exam? - every 45 days - 20 days before the exam Payments of medical services required to treat work related injuries and illnesses are governed by the _____ guidelines? Official Medical Fee Schedule (OMFS) Which form is filed by the PTP once the employee has reach Permanent and Stationary status? 92 | P a g e PR-4 How many days must the pre-authorization decisions be communicated to the requesting physician? 1 day True or false, a WCAB Judge determine factors of disability, then will request that the DEU issue a rating? True True or false, medical treatment and med-legal disputes are resolved through the Independent Bill Review (IBR) process? True If a QME communicates with one party in a case, the QME then has _____ days to communicate with the other party? 10 days True or false: impairment is a measure of how an injury alters an individuals capacity to work? True The burden of proof of CAUSATION falls on which party? Employer (defendant) The burden of proof of an INJURY falls on which party? Employee In cases made P&S before 01/01/2005 the permanent disability rating is based upon what three things? 1. Subjective factors of disability 2. objective factors 3. work restrictions/preclusion With a starting date of _____, physical injury cases, sleep, sex, and psych impairments are not ratable without direct cause. However, they can still be treated for them? 01/01/2013 A Non-AME (QME) must reschedule a CANCELLED appointment within _____ days of the original scheduled appointment and within _____ days of the initial request, unless parties agree in writing to accept a date past that. 30 days, 60 days An AME must reschedule a cancelled appointment within _____ days of the original scheduled appointment, but can be extended to _____ days if both parties agree? 60, 90 (30 more days than QME) 95 | P a g e 1. Formal 2. Consultative 3. Summary When is a Formal Rating prepared by the DEU? At the request of a WC judge When is a consultative rating prepared by the DEU? Litigated cases at the request of an Attorney or an I&A Officer When is a summary rating prepared by the DEU? Non-litigated cases at the request of a claims administrator or IW Who is the first DWC contact for Injured Workers? The Information and Assistance (I&A) Unit _____________ officers assist in the resolution of misunderstandings, disputes, and complaints and conduct monthly seminars at each of the 24 local district offices. Information and Assistance (I&A) How are claims paid when illegally uninsured employers fail to pay workers' compensation benefits awarded to their injured employees? Uninsured Employers Benefits Trust Fund (UEBTF) Employees are obligated to authorize up to $_____ of medical treatment within 1 working day after the claim is filed? $10,000 The ______________ is a source of additional compensation to injured workers who already had a disability impairment at the time of injury? Subsequent Injuries Benefits Trust Fund (SIBTF) For benefits to be paid from the SIBTF, the combined effect of the injury and the previous disability or impairment must result in a permanent disability of at least _____% 70% When can benefits be reduced by half? reduced when injury is result of employee serious and willful misconduct (unless result is death or permanent disability of 70% or more) When can benefits be be increased by half? When an injury is result of Employer serious and willful misconduct. What fund did the Boynton Act of 1913 establish? 96 | P a g e State Compensation Insurance Fund (SCIF) The Boynton Act required what? Most employers to have WC coverage What is the purpose of Utilization Review (UR)? Its purpose is to determine whether a requested treatment is medically necessary. What is the PR-4 form? Used to indicate the IW's condition has become P&S/MMI What is an aggravation? Irritation of a NON-INDUSTRIAL pre-existing injury that can be filed as a new claim What is a flare-up? Irritation of a previous INDUSTRIAL injury that cannot be filed as a new claim What is the Medical Treatment Utilization Schedule (MTUS)? Evidence Based Medicine treatments guidelines for treating IW's. It must also be used in the UR and IMR process Temporary Disability benefits are not paid for the first 3 days unless the IW is _____ and _____? 1. Hospitalized 2. Misses more than 14 days of work How does the MTUS help medical providers? 1. Helps providers understand which EBM treatments have been effective for IW's. 2. It also recommends the frequency, intensity and duration of treatment. What are the 4 basic conditions for a WC claim? 1. Must have an Injury 2. Employment relationship 3. AOE 4. COE What year was Pain given a 1-3% value? 2003 When can Pain (1-3%) be added to the total WPI? When the pain level is unusually high. Some pain is expected in an injury but it is up to the physician to determine if the pain experienced is above normal. What does CA Labor Code section 132a state? 97 | P a g e 1. An employer can't discriminate (retaliate) against an employee for filing a WC claim 2. Employer cannot discriminate against other employees that may testify in the employees case. A medical-legal cost is defined as a cost for what? Specified services incurred to prove or disprove a contested case How many days does a QME have to submit a follow-up comprehensive medical-legal evaluation? 30 days Temporary Disability benefits are not paid for the first _____ days? 3 days (unless the IW is hospitalized or missed more than 14 days of work) Temporary Disability benefits must begin within _____ days of the claim? (unless the employer contests the claim) 14 days The cost of treatment must include current medical treatment and _____? Future treatment After 01/01/2008, Temporary Disability benefits may last up to _____ weeks within _____ years of DOI? 1. 104 weeks 2. 5 year What is weekly the minimum and maximum Temporary Disability payments before 01/01/2005? $105 (min) $270 (max) What is weekly the minimum and maximum Temporary Disability payments between 01/01/2005 - 01/01/2014? $130 (min) $270 (max) What is the weekly minimum and maximum Temporary Disability payments after 01/01/2014? $160 (min) $290 (max) When can an IW receive Supplemental Job Displacement Benefits (SJDB)? Injury after 01/01/2004 and have PPD that prevents IW from doing their old job and the employer does not offer IW new work, IW can receive a SJDB voucher. IW's with Permanent Partial Disability of 70% or more will receive _____? A small pension for life after their Permanent Disability benefits are depleted