DWC 15th Annual Educational Conference

Los Angeles Sheraton February 28-29, 2008 Oakland Marriot March 3-4, 2008

QME Update

Presenters

Sue Honor-Vangerov

QM

E R

egul

atio

ns U

pdat

eD

WC

Edu

catio

nal C

onfe

renc

e 20

08

Suz

anne

Hon

or

Wor

kers

’Com

pens

atio

n M

anag

er, D

WC

Med

ical

Uni

t

Suz

anne

Mar

riaIn

dust

rial R

elat

ions

Cou

nsel

III,

DW

C L

egal

Uni

t

QM

E R

egul

atio

n R

ulem

akin

g•

Sta

rted

Nov

embe

r 200

7•

Cov

ers

all Q

ME

regu

latio

ns a

nd fo

rms

(§§

1 –

159,

Titl

e 8

Cal

iforn

ia C

ode

of R

egul

atio

ns [8

CC

R]

•H

ad 4

5 da

y pu

blic

com

men

t per

iod

and

publ

ic h

earin

gs•

DW

C is

revi

ewin

g th

e co

mm

ents

now

•W

ill p

ublic

ly re

leas

e an

d po

st re

visi

ons

for a

dditi

onal

15

day

publ

ic w

ritte

n co

mm

ent p

erio

d•

Pro

pose

d re

gula

tions

at

http

://w

ww

.dir.

ca.g

ov/d

wc/

DW

CP

ropR

egs/

qme_

regu

latio

ns/q

me_

regu

latio

ns.h

tm•

Ann

ounc

emen

ts o

f pub

lic c

omm

ent p

erio

ds a

t ht

tp://

ww

w.d

ir.ca

.gov

/dw

c/dw

cRul

emak

ing.

htm

Hig

hlig

hts

of W

hat’s

New

•S

ome,

not

all

chan

ges

•D

efin

ition

s•

Pan

el P

roce

ss a

nd P

anel

Req

uest

For

ms

•Q

ME

Spe

cifie

d Fi

nanc

ial I

nter

ests

•Q

ME

Con

flict

s of

Inte

rest

dis

clos

ure

•G

roun

ds fo

r Rep

laci

ng a

Pan

el Q

ME

•Q

ME

Min

imum

Ava

ilabi

lity

for P

anel

s•

Lim

it on

QM

E o

ffice

loca

tions

list

ed w

ith

DW

C

Sco

pe o

f Reg

ulat

ion

Cha

nges

•U

pdat

e pe

r ref

orm

s by

SB

228

/AB

227

& S

B 8

99–

Aut

horit

y fo

r QM

Es

trans

ferre

d to

A.D

.–

Cha

nges

to L

C 4

060,

406

1 an

d 40

62•

Whe

n em

ploy

er m

ay re

ques

t QM

E p

anel

in u

nrep

rese

nted

cas

e(L

C 4

062.

1(b)

; LC

406

0(d)

)–

LC 4

062.

1 –

QM

E p

anel

pro

cess

for u

nrep

rese

nted

Inju

red

Wor

ker

(IW)

–LC

406

2.2

–A

ME

or Q

ME

pan

el p

roce

ss fo

r rep

rese

nted

cas

es w

ith

date

of i

njur

y (D

OI)

on/a

fter 1

/1/2

005

–LC

406

2.3

-Inf

orm

atio

n ex

chan

ge: E

x pa

rte c

omm

unic

atio

n w

ith

AM

E o

r QM

E–

Sec

tion

47 o

f SB

899

–m

ade

chan

ges

in S

B 8

99 a

pply

‘p

rosp

ectiv

ely’

from

4/1

9/04

to a

ll ca

ses

‘rega

rdle

ss o

f the

dat

e of

in

jury

, unl

ess

othe

rwis

e sp

ecifi

ed…

’•

Upd

ate

to c

onfo

rm to

cas

e la

w fr

om W

CA

B a

nd c

ourts

–P

rece

dent

val

ue:

–C

A S

upre

me

Cou

rt>C

ourt

of A

ppea

l>W

CA

B e

n ba

nc >

Sig

nific

ant

Pan

el d

ecis

ions

>WC

AB

pan

el d

ecis

ion

–W

CA

B e

n ba

nc d

ecis

ion

are

bind

ing

on a

ll W

CA

B p

anel

s an

d W

CA

LJs

(Sim

mon

s v.

WC

AB

)

New

or C

hang

ed D

efin

ition

s P

ropo

sed

•A

OE/

CO

E(§

1(f))

–Fo

r pur

pose

s of

QM

E re

gula

tions

and

form

s–

Dis

pute

ove

r com

pens

abili

ty n

eedi

ng m

edic

al o

pini

on–

See

sec

tion

30(d

) and

pan

el re

ques

t for

ms

in s

ectio

ns 1

05

and

106

•C

laim

s ad

min

istr

ator

(§1(

j))–

Add

s U

EB

TF a

fter p

rope

r ser

vice

and

join

der

•Em

ploy

er(§

1(r)

)–

Add

s in

sure

d em

ploy

er, s

elf i

nsur

ed e

mpl

oyer

, law

fully

un

insu

red

empl

oyer

to U

EB

TF a

fter p

rope

r ser

vice

and

jo

inde

r

Def

initi

ons

–co

nt.

•Fo

llow

up

and

Supp

lem

enta

lcom

preh

ensi

ve

med

ical

/lega

l rep

orts

–Fo

llow

Up

(§1(

t)):

in-p

erso

n ex

amin

atio

n –

Sup

plem

enta

l (§

1(ee

)):

only

revi

ew o

f med

ical

test

re

sults

or r

ecor

ds

•Sp

ecifi

ed F

inan

cial

Inte

rest

(§1(

dd))

diff

eren

t tha

n ‘S

igni

fican

t Fin

anci

al In

tere

st o

r Affi

liatio

n H

eld

by

Facu

lty’

(§1

(cc)

) of c

ontin

uing

edu

catio

n pr

ovid

er•

Prim

ary

prac

tice

loca

tion

(§1

(x))

•A

CO

EM, A

MA

Gui

des,

Med

ical

Tre

atm

ent U

tiliz

atio

n Sc

hedu

le (M

TUS)

all d

efin

ed•

QM

E C

ompe

tenc

y Ex

am fo

r Acu

punc

turis

ts –

see

§§

1(aa

) and

11(

f)

QM

E P

anel

Pro

cess

Thro

ugh

the

Look

ing

Gla

ss•

Whe

n C

an Y

ou R

eque

st a

Pan

el?

•W

ho C

an R

eque

st a

Pan

el?

•W

hich

Tra

ck –

Rep

rese

nted

or

Unr

epre

sent

ed?

•W

hat D

o Y

ou S

end

the

Med

ical

Uni

t?•

Why

the

Med

ical

Uni

t Ask

s fo

r Mor

e In

fo?

•R

epla

cem

ent Q

ME

sor

QM

E P

anel

s•

Late

Rep

orts

Whe

n C

an a

QM

E P

anel

Be

Req

uest

ed?

•Fo

r com

pens

abili

tydu

ring

90 d

ay p

erio

d af

ter

clai

m fo

rm fi

led

(e.g

. bef

ore

clai

mde

nied

)–

Rep

rese

nted

IW c

ase

Mus

t fol

low

AM

E/Q

ME

pro

cess

in L

C 4

062.

2 (L

C

4060

(c))

–U

nrep

rese

nted

IW c

ase

Mus

t fol

low

LC

406

0(d)

and

406

2.1

•E

mpl

oyer

/cla

ims

adm

inis

trato

r mus

t not

ify

unre

pres

ente

d in

jure

d w

orke

r eith

er:

–E

mpl

oyer

is re

ques

ting

an e

valu

atio

n to

det

erm

ine

com

pens

abili

ty, o

r–

Em

ploy

er h

as n

ot a

ccep

ted

liabi

lity

and

the

IW e

mpl

oyee

m

ay re

ques

t a Q

ME

pan

el to

det

erm

ine

com

pens

abili

ty•

Obt

ain

QM

E p

anel

onl

y th

roug

h pr

oces

s in

LC

40

62.1

•A

ftera

dis

pute

exi

sts

–D

ispu

te o

n m

edic

al tr

eatm

ent o

pini

ons

by

PTP

(LC

406

2) o

r dis

pute

per

man

ent

impa

irmen

t or d

isab

ility

opi

nion

(LC

406

1)–

Inju

red

wor

ker m

ay d

ispu

te U

R d

enia

l, de

lay

or m

odifi

catio

n (L

C 4

062)

–If

any

body

par

t acc

epte

d, L

C 4

060

does

not

ap

ply

(see

, LC

406

0(a)

). T

here

fore

onc

e em

ploy

er/c

laim

s ad

min

istra

tor a

ccep

ts a

ny

part

of c

laim

Whe

n C

an a

QM

E P

anel

Be

Req

uest

ed –

cont

.?

Who

Can

Req

uest

a P

anel

? •

Inju

red

Wor

ker:

–A

fter t

he e

mpl

oyer

/cla

ims

adm

inis

trato

r de

nies

the

clai

men

tirel

y du

ring

the

first

90

days

(LC

406

0)–

Afte

r IW

mak

es ti

mel

y ob

ject

ion

to U

R

deci

sion

that

del

ays,

mod

ifies

or d

enie

s tre

atm

ent (

LC 4

062(

a))

–A

fter I

W m

akes

tim

ely

obje

ctio

n to

em

ploy

er/c

laim

s ad

min

istra

tor’s

not

ice

rega

rdin

g pe

rman

ent i

mpa

irmen

t or d

isab

ility

(L

C 4

061)

–W

hen

empl

oyer

/cla

ims

adm

inis

trato

r pro

vide

s th

e Q

ME

pan

el re

ques

t for

m w

ith a

requ

est t

o fil

e th

e fo

rm w

ithin

10

days

of r

ecei

pt d

ue to

em

ploy

er/c

laim

adm

inis

trato

r’s ti

mel

y

Who

Can

Req

uest

a P

anel

–co

nt.?

•E

mpl

oyer

/cla

ims

adm

inis

trato

r:–

Unr

epre

sent

ed IW

cas

e: O

nly

afte

r gi

ving

IW p

rope

r and

tim

ely

notic

es o

f na

ture

of o

bjec

tion/

disp

ute;

pro

vide

IW

with

a Q

ME

requ

est f

orm

, ins

truct

ions

an

d a

requ

est t

o fil

e it

with

the

Med

ical

U

nit w

ithin

10

days

; and

at l

east

10

days

ha

ve p

asse

d si

nce

it w

as fu

rnis

hed

to IW

(L

C 4

062.

1(b)

)–

Rep

rese

nted

cas

e [D

OI p

ost 1

/1/0

5]:

Onl

y af

ter c

ompl

ying

with

LC

406

2.2

AM

E/Q

ME

dan

ce re

quire

men

ts

Pan

el P

roce

ss –

Rep

rese

nted

IW•

DO

I on/

afte

r 1/1

/200

5:–

LC 4

062.

2 pr

oces

s–

Agr

ee o

n A

ME

per

LC

, or

–R

ace

to g

et p

anel

QM

E•

Med

ical

Uni

t will

pro

cess

firs

t com

plet

e an

d pr

oper

re

ques

t rec

eive

d (L

C 4

062.

2)•

Pro

pose

d §

31.1

: If

two

rece

ived

on

the

sam

e da

y re

ques

ting

diffe

rent

spe

cial

ties

in s

ame

case

, Med

ical

D

irect

or w

ill u

se s

ame

spec

ialty

as

treat

ing

phys

icia

n un

less

:–

Per

suad

ed b

y pa

rty e

vide

nce

supp

ortin

g re

ques

ted

spec

ialty

–N

eith

er p

arty

requ

ests

sam

e sp

ecia

lty a

s P

TP a

nd

Med

ical

Dire

ctor

det

erm

ines

ano

ther

spe

cial

ty

mor

e ap

prop

riate

•D

OI 1

/1/1

994

to 1

2/31

/04:

–E

ach

party

sel

ects

ow

n Q

ME

for a

ll di

sput

ed

inju

ries

(Sim

i v. S

ave-

Max

Foo

ds, I

nc. (

2005

) 70

Cal

. Cas

es 2

17

en b

anc)

–C

an’t

use

LC 4

050

or 4

064

to c

ircum

vent

LC

40

62.2

pro

cess

(N

unez

v. W

CA

B(2

006)

136

Cal

. App

. 4th

584,

71

Cal

. Com

p. C

as16

1; C

orte

z v.

WC

AB

(200

6) 1

36 C

al. A

pp. 4

th59

6, 7

1 C

al. C

omp.

C

as15

5; W

ard

v. C

ity o

f Des

ert H

ot S

prin

gs (2

006)

71

Cal

. Com

p.

Cas

1313

(sig

nific

ant p

anel

dec

isio

n))

–G

ener

ally

one

QM

E fo

r all

med

ical

issu

es, b

ut

appl

ican

t ent

itled

to a

s m

any

repo

rts a

s de

fens

e(G

ubbi

nsv

WC

AB

(199

7) 6

2 C

al. C

omp.

Cas

946)

•W

indo

w P

erio

d D

OI 1

/1/9

1 –

12/3

1/93

:–

Eac

h pa

rty s

elec

ts o

wn

QM

E fo

r eac

h ne

eded

Pan

el P

roce

ss –

Rep

rese

nted

IW co

nt.

Pan

el P

roce

ss –

Unr

epre

sent

ed IW

•A

ll D

OIs

•In

jure

d w

orke

r (IW

) mus

t:–

Sig

n pa

nel r

eque

st fo

rm;

–S

elec

t spe

cial

ty fo

r QM

E p

anel

; and

–S

elec

t a Q

ME

from

the

pane

l iss

ued

–S

ched

ule

an a

ppoi

ntm

ent w

ith Q

ME

•E

xcep

tem

ploy

er/c

laim

s ad

min

istra

tor m

ay re

ques

t pan

el

and

spec

ify s

peci

alty

:–

If em

ploy

er s

ent t

he IW

the

pane

l req

uest

form

(For

m 1

05 a

nd

Atta

chm

ent t

o 10

5), a

nd–

10 c

alen

dar d

ays

have

pas

sed

–IW

faile

d to

sen

d pa

nel r

eque

st to

Med

ical

Uni

t (LC

406

2.1(

b))

•A

lso

Em

ploy

er m

ay s

elec

t QM

E fr

om p

anel

list

–If

IW fa

ils to

sel

ect Q

ME

from

pan

el a

nd in

form

em

ploy

er o

f se

lect

ion

with

in 1

0 da

ys o

f iss

uanc

e of

QM

E p

anel

(LC

406

2.1(

c))

Unr

epre

sent

ed →

Rep

rese

nted

–If

unre

pres

ente

d IW

‘rec

eive

d’a

QM

E

eval

uatio

n an

d la

ter b

ecam

e re

pres

ente

d, n

ot e

ntitl

ed to

ano

ther

ev

alua

tion

(LC

406

2.1(

e); L

C

4062

.2(e

)).–

How

ever

, IW

has

“rec

eive

d”ev

alua

tion

only

afte

r IW

atte

nds

and

parti

cipa

tes

in

eval

uatio

n.(R

omer

o v.

Cos

tco

(200

7) 7

2 C

al. C

omp.

Cas

es

824)

Pan

el P

roce

ss

Wha

t to

Sen

d M

edic

al U

nit-

Rep

rese

nted

Cas

e•

Rep

rese

nted

DO

I on/

afte

r 1/1

/200

5–

Doc

umen

t sho

win

g w

hat i

s in

dis

pute

that

nee

ds m

edic

al o

pini

on to

re

solv

e

(LC

406

2.2(

a))

–W

ritte

nof

fer t

o ot

her p

arty

of A

ME

nam

ing

at le

ast o

ne p

hysi

cian

(LC

406

2.2(

b))

–N

o so

oner

than

10

days

afte

r the

firs

t writ

ten

AM

E pr

opos

al:

•Q

ME

pan

el re

ques

t for

m 1

06•

Form

com

plet

ed a

nd s

igne

d•

Iden

tify

date

of i

njur

y-

Sta

te Q

ME

spe

cial

ty re

ques

ted,

spe

cial

ty o

f tre

atin

g ph

ysic

ian

and

spec

ialty

pre

ferr

ed b

y ot

her p

arty

, if k

now

n (L

C 4

062.

2(b)

-P

roof

of S

ervi

ce o

n ot

her p

arty

-C

anno

t req

uest

QM

E pa

nel i

f is

obje

ctio

n to

spin

al s

urge

ry-

Par

ties

mus

t use

spi

nal s

urge

ry s

econ

d op

inio

n pr

oces

s un

der L

C

4062

(b) a

nd 8

CC

R §

§97

88.0

1 to

978

8.91

Pan

el P

roce

ssW

hat t

o S

end

Med

ical

Uni

t -U

nrep

rese

nted

C

ase

•R

eque

st fr

om IW

–Q

ME

pan

el re

ques

t for

m 1

05•

Form

com

plet

ed; d

ate

of in

jury

sta

ted

•S

igne

dby

IW

•R

eque

st fr

om e

mpl

oyer

/cla

ims

adm

inis

trat

or–

QM

E p

anel

requ

est f

orm

105

•Fo

rm c

ompl

eted

; dat

e of

inju

ry s

tate

d•

Sig

ned

by C

A–

Doc

umen

t sho

win

g tim

ely

obje

ctio

n by

CA

•In

jure

d w

orke

r (IW

) obj

ectio

n to

UR

dec

isio

n m

odify

ing,

del

ayin

gor

de

nyin

g m

edic

al tr

eatm

ent r

ecom

men

ded

by P

TP (L

C 4

062(

a))

–C

opy

of p

rope

r not

ices

to IW

abo

ut ri

ght t

o re

ques

t QM

E p

anel

, to

sele

ct

QM

E p

anel

spe

cial

ty, r

eque

st IW

to s

ubm

it th

e fo

rm a

nd ti

me

limit

for

send

ing

QM

E p

anel

form

to M

edic

al U

nit

•Po

stm

ark

mor

e th

an 1

0 da

ys a

fter f

orm

furn

ishe

d to

IW

Whe

n th

e M

edic

al U

nit A

sks

for

Info

rmat

ion

•R

easo

ns: i

ncom

plet

e in

form

atio

n fil

ed w

ith p

anel

re

ques

t•

Med

ical

Uni

t dat

abas

e sh

ows

a Q

ME

pan

el

alre

ady

was

issu

ed fo

r thi

s in

jure

d w

orke

r–

MU

nee

ds to

find

out

if p

anel

was

use

d an

d Q

ME

re

port

alre

ady

was

issu

ed o

n di

sput

ed is

sue

–LC

406

2.3(

i)–

LC 4

062.

3(j)

•E

xam

ples

–S

ame

inju

red

wor

ker;

diffe

rent

par

ties

–S

ame

inju

red

wor

ker;

diffe

rent

bod

y pa

rt–

Sam

e in

jure

d w

orke

r; di

ffere

nt d

ate

of in

jury

Pro

blem

Are

as

•S

pina

l Sur

gery

dis

pute

s•

MP

N d

ispu

tes

•U

R a

nd C

ausa

tion

Dis

pute

s•

Oth

er p

robl

ems

with

PTP

Spi

nal S

urge

ry d

ispu

tes

•V

ery

shor

t tim

elin

es to

obj

ect t

o P

TP re

com

men

datio

n fo

r sp

inal

sur

gery

und

er L

C 4

062(

b) a

nd p

roce

dure

s in

8 C

CR

§§

9788

.01

–97

88.9

1•

10 c

alen

dar d

ays

of re

ceip

t of P

TP re

port

reco

mm

endi

ng

spin

al s

urge

ry (L

C 4

062(

b))

•Fi

le D

WC

For

m 2

33 (8

CC

R §

9788

.1(a

))•

Em

ploy

er’s

opt

ions

, per

WC

AB

, whe

n P

TP re

com

men

ds

spin

al s

urge

ry:

–A

utho

rize

the

surg

ery;

or

–O

bjec

t und

er L

C 4

062

and

file

DW

C F

or 2

33 w

ith th

e M

edic

al U

nit

with

in 1

0 da

ys o

f rec

eipt

of t

he d

octo

r’s re

com

men

datio

n; o

r–

Sen

d th

e re

com

men

ded

treat

men

t thr

ough

util

izat

ion

revi

ew (U

R);

or–

Sim

ulta

neou

sly,

obj

ect u

nder

LC

406

2 by

filin

g D

WC

233

and

sen

d th

e re

com

men

datio

n th

roug

h U

R, o

r if s

till t

imel

y af

ter r

ecei

ve U

R

deni

al, t

hen

obje

ct a

nd fi

le D

WC

233

–B

rash

er v

. Nat

ionw

ide

Stu

dio

Fund

(200

6) 7

1 C

al. C

omp.

Cas

1282

(s

igni

fican

t pan

el d

ecis

ion)

•C

anno

task

for Q

ME

pan

el

MP

N D

ispu

tes

IW in

MP

N d

ispu

tes

PTP

opi

nion

on

diag

nosi

s or

tre

atm

ent:

•IW

mus

t sel

ect 2

ndop

inio

n fro

m a

phy

sici

an in

th

e M

PN

and

, if n

eede

d, a

3rd

opin

ion,

then

if IW

st

ill o

bjec

ts, r

eque

st in

depe

nden

t med

ical

revi

ew

(IMR

) (s

ee, 8

CC

R §

§97

67.7

, 976

8.9)

•

If IM

R p

hysi

cian

dis

agre

es w

ith 3

rdop

inio

n ph

ysic

ian,

IW m

ay s

elec

t any

phy

sici

an in

side

or

outs

ide

of M

PN

for t

reat

men

t or d

iagn

ostic

se

rvic

e ap

prov

ed b

y IM

R p

hysi

cian

(8 C

CR

§97

68.1

7)

With

MP

N, W

hen

AM

E/Q

ME

App

lies

•Fo

r UR

dis

pute

, IW

may

mak

e tim

ely

obje

ctio

n un

der L

C §

4062

and

get

AM

E o

r Q

ME

•Fo

r any

dis

pute

und

er L

C §

4061

or 4

062

eith

er p

arty

may

go

thro

ugh

the

AM

E/Q

ME

pr

oces

s as

app

ropr

iate

.

MP

N D

ispu

tes

•“N

o ad

ditio

nal e

xam

inat

ions

sha

ll be

or

dere

d by

the

appe

als

boar

d an

d no

oth

er

repo

rts s

hall

be a

dmis

sibl

e to

reso

lve

any

cont

rove

rsy

aris

ing

out o

f thi

s (M

PN

) ar

ticle

.”(L

C 4

616.

6)•

Onl

y W

CA

LJ c

an re

solv

e fa

ctua

l MP

N

cove

rage

dis

pute

s:–

Whe

ther

IW c

over

ed b

y M

PN

–W

heth

er p

rope

r not

ice

of M

PN

or p

rope

r tra

nsfe

r int

o M

PN

giv

en to

IW–

Whe

ther

MP

N h

as s

peci

alis

t com

pete

nt to

trea

t in

jury

UR

Cau

satio

n D

ispu

tes

•W

hen

empl

oyer

/cla

ims

adm

inis

trato

r firs

t le

arns

from

UR

revi

ewin

g ph

ysic

ian

that

th

e cl

aim

ed in

jury

may

not

aris

e ou

t of o

r ha

ve o

ccur

red

in th

e co

urse

of

empl

oym

ent,

mus

t fol

low

pro

cedu

re in

S

imm

ons

v W

CA

Bto

avo

id U

R p

enal

ties

and

to g

et a

dmis

sibl

e m

edic

al/le

gal r

epor

t

Med

ical

ly N

eces

sary

But

Cau

sal

Link

Que

stio

ned

•Tw

o st

ep d

ecis

ion

proc

ess

avoi

ds p

robl

em•

Is re

ques

ted

treat

men

t med

ical

ly n

eces

sary

?–

If no

, den

y on

med

ical

nec

essi

ty a

lone

–If

yes,

sta

te m

edic

ally

nec

essa

ry, a

dd c

linic

al re

ason

ing

that

su

ppor

ts m

edic

al o

pini

on re

gard

ing

whe

ther

nee

d fo

r tre

atm

ent

aris

es fr

om c

laim

ed in

jury

and

sen

d re

port

to a

djus

ter

•Le

t adj

uste

r iss

ue U

R d

enia

l in

relia

nce

on a

ttach

ed U

R

phys

icia

n re

port

and

issu

e ob

ject

ion

unde

r LC

406

2;•

Den

ial b

ased

on

caus

atio

n w

ithou

t med

ical

nec

essi

ty

dete

rmin

atio

n fro

m U

R p

hysi

cian

to re

ques

tor–

viol

ates

8

CC

R 9

792.

6(s)

, 979

2.9(

j) an

d S

imm

ons

en b

anc

WC

AB

de

cisi

on•

Den

ial b

y ad

just

er o

r RN

cas

e m

anag

er w

ithou

t UR

ph

ysic

ian

repo

rt on

med

ical

nec

essi

ty a

ttach

ed v

iola

tes

LC 4

610(

e), L

C 4

610(

a), 8

CC

R 9

792.

6(s)

and

Sim

mon

s

Med

ical

ly N

eces

sary

But

…co

n’t.

•“W

hen

a U

R p

hysi

cian

find

s th

at re

ques

ted

treat

men

t is

med

ical

ly n

eces

sary

but

que

stio

ns

whe

ther

the

need

for t

hat t

reat

men

t is

caus

ally

re

late

d to

the

indu

stria

l inj

ury,

the

defe

ndan

tmus

t ei

ther

: (a)

aut

horiz

e th

e tre

atm

ent;

or (b

) tim

ely

deny

aut

horiz

atio

n ba

sed

on c

ausa

tion’

with

in th

e de

adlin

es in

LC

461

0(g)

(3)(

A) a

nd ‘t

imel

y in

itiat

e th

e A

ME

/QM

E p

roce

ss’w

ithin

the

spec

ified

tim

e lim

its u

nder

LC

406

2(a)

.’‘If

def

enda

nt d

ecid

es to

de

ny a

utho

rizat

ion

for c

oncu

rren

t or p

rosp

ectiv

e tre

atm

ent b

ased

on

a qu

estio

n ar

isin

g in

util

izat

ion

revi

ew re

gard

ing

the

treat

men

t’s c

ausa

l co

nnec

tion

to th

e in

jury

then

the

defe

ndan

t mus

t re

ach

this

dec

isio

n to

den

y w

ithin

the

time

dead

lines

est

ablis

hed

by s

ectio

n 46

10.’

(Sim

mon

s v

Sta

teof

Cal

iforn

iaS

CIF

(200

5)W

CA

Ben

banc

Oth

er P

TP P

robl

ems

•P

TP w

ill n

ot is

sue

P&

S re

port:

–N

on M

PN

phy

sici

an: P

etiti

on fo

r Cha

nge

of T

reat

ing

Phy

sici

an (s

ee, L

C §

4603

, 8 C

CR

§§

9786

, 978

6.1,

97

87)

–M

PN

phy

sici

an:

Obj

ect u

nder

LC

§40

62 a

nd 8

CC

R §

9767

.10(

d)(3

))•

PTP

dis

cuss

ion

on p

erm

anen

t im

pairm

ent a

nd

disa

bilit

y no

t com

plia

nt w

ith A

MA

gui

des

•D

ispu

te o

ver d

eter

min

atio

n ov

er IW

ent

itlem

ent t

o co

ntin

uity

of c

are

with

non

-MN

P o

r ter

min

ated

MP

N

PTP:

–O

bjec

t und

er L

C §

4062

and

8 C

CR

§97

67.1

0(d)

(3))

Wha

t’s N

ew a

bout

Pan

el

Req

uest

s in

QM

E R

egs?

•P

anel

Req

uest

For

ms

–Fo

rm 1

05 –

Unr

epre

sent

ed c

ases

–Fo

rm 1

06 –

Rep

rese

nted

cas

es•

Onc

e en

tire

clai

m is

den

ied

durin

g 90

day

per

iod,

onl

y th

e in

jure

d w

orke

r or h

is/h

er re

pres

enta

tive

may

re

ques

t pan

el u

nder

LC

406

0 to

det

erm

ine

com

pens

abili

ty (p

ropo

sed

8 C

CR

§30

(d)(

3))

Wha

t’s N

ew a

bout

Pan

el R

eque

sts

in Q

ME

Reg

s–

cont

.?•

If ne

ed Q

ME

eva

luat

ion

to d

eter

min

e co

mpe

nsab

ility

afte

r cla

im a

ccep

ted

or ‘f

or g

ood

caus

e’af

ter p

resu

mpt

ion

of c

ompe

nsab

ility

in L

C

5402

(b):

–E

ither

get

‘fol

low

up’

or ‘s

uppl

emen

tal’

eval

uatio

n fro

m

the

AM

E o

r QM

E w

ho a

lread

y re

porte

d in

the

case

; or

–If

no p

rior e

valu

atio

n, if

prio

r eva

luat

or is

una

vaila

ble

or n

ot m

edic

ally

qua

lifie

d to

add

ress

, mus

t pro

vide

su

ppor

ting

evid

ence

suc

h as

a d

escr

iptio

n of

new

ly

disc

over

ed e

vide

nce

not a

vaila

ble

durin

g 90

day

s or

ex

plan

atio

n of

the

reas

on fo

r a c

ompe

nsab

ility

ev

alua

tion

at th

is ti

me

(pro

pose

d 8

CC

R §

30(d

)(4)

)•

Mus

t be

5 ac

tive

QM

Es

in s

peci

alty

requ

este

d to

issu

e pa

nel o

r Med

ical

Dire

ctor

will

ask

re

ques

tort

ose

lect

anot

hers

peci

alty

(pro

pose

d

Look

at F

orm

s 10

5 an

d 10

6

QM

E D

iscl

osur

e of

Spe

cifie

d Fi

nanc

ial I

nter

ests

•P

ropo

sed:

QM

Es

will

be

requ

ired

to d

iscl

ose

‘spe

cifie

d fin

anci

al in

tere

sts’

and

upda

te th

e di

sclo

sure

form

ann

ually

(p

ropo

sed

8 C

CR

§29

)•

Gen

eral

ly in

volv

es o

wne

rshi

p or

fina

ncia

l in

tere

sts

of 5

% o

f mor

e of

spe

cifie

d bu

sine

sses

•A

D w

ill u

se in

form

atio

n to

atte

mpt

to a

void

as

sign

ing

two

phys

icia

ns w

ith a

sha

red

finan

cial

in

tere

st to

the

sam

e Q

ME

pan

el•

Par

ty c

an re

ques

t a re

plac

emen

t for

QM

Es

who

ha

ve s

hare

d fin

anci

al in

tere

sts

and

appe

ar o

n th

e sa

me

pane

l

QM

E C

onfli

cts

of In

tere

st•

Cur

rent

: 8

CC

R §

§41

(c)(1

) and

41(

c)(4

)•

Pro

pose

d pe

r LC

139

.2(o

):–

8 C

CR

§41

.5 p

rohi

bits

eva

luat

ors

from

re

ques

ting

or a

ccep

ting

any

com

pens

atio

n or

ot

her t

hing

of v

alue

from

any

sou

rce

that

doe

s or

cou

ld c

reat

e a

conf

lict w

ith th

e du

ties

as a

n ev

alua

tor

–C

onfli

ct w

ith th

e du

ties

of a

n ev

alua

tor i

s de

fined

as

havi

ng a

‘dis

qual

ifyin

g’co

nflic

t of

inte

rest

with

one

or m

ore

pers

ons

or e

ntiti

es

invo

lved

in th

e ca

se a

nd fa

iling

to d

iscl

ose

the

conf

lict (

prop

osed

§41

.5(b

))–

‘Dis

qual

ifyin

g’co

nflic

ts d

efin

ed b

y sp

ecifi

c fa

mili

al, b

usin

ess,

pro

fess

iona

l or o

ther

re

latio

nshi

ps

QM

E C

onfli

cts

of In

tere

st –

cont

.•

Pro

cedu

res

prop

osed

–

AM

E o

r QM

E m

ay s

elf d

isqu

alify

due

to c

onfli

ct

of in

tere

st–

Par

ties

may

obj

ect t

o A

ME

or Q

ME

due

to

alle

ged

conf

lict

–O

nce

conf

lict d

iscl

osed

or r

aise

d, p

roce

dure

for

each

par

ty to

sta

te w

heth

er th

e pa

rty w

ill w

aive

th

e co

nflic

t or o

bjec

t to

the

eval

uato

r–

Dis

pute

s ov

er w

heth

er c

onfli

ct e

xist

s to

be

reso

lved

by

a W

CA

LJ•

AM

Es

and

QM

Es

will

not b

e al

low

ed to

ac

cept

gift

s ha

ving

a fa

ir m

arke

t val

ue o

ver $

36

0 fro

m a

ny s

ingl

e so

urce

in a

ny 1

2 m

onth

pe

riod

(pro

pose

d§

417)

Gro

unds

for R

epla

cing

a P

anel

Q

ME

•E

xist

ing

reas

ons

in §

31.5

with

som

e m

odifi

catio

ns•

Obj

ectio

ns e

xpan

ded

to ‘p

arty

hol

ding

le

gal r

ight

to re

ques

t the

pan

el’

•P

rimar

y or

sec

onda

ry P

TP s

tatu

s ad

ded

•Fa

ilure

to is

sue

repo

rt w

ithin

dea

dlin

es in

LC

406

2.5

and

prop

osed

8 C

CC

§38

Gro

unds

for R

epla

cing

a

Pan

el Q

ME

–co

nt.

•D

isqu

alify

ing

conf

lict o

f int

eres

t per

41.

5•

Ord

er b

y A

.D. f

or a

dditi

onal

QM

E•

Upo

n sh

owin

g of

goo

d ca

use

that

an

addi

tiona

l Q

ME

in a

diff

eren

t spe

cial

ty is

nee

ded

(see

pro

pose

d §

31.5

(b))

–B

y or

der o

f WC

ALJ

–W

hen

AM

E o

r QM

E s

tatu

es n

eed

for i

ssue

s ou

tsid

e ow

n sp

ecia

lty–

Par

ties

in re

pres

ente

d ca

se a

gree

nee

d bu

t fai

l to

agre

e on

AM

E–

In u

nrep

rese

nted

cas

e, w

hen

parti

es m

eet w

ith I

& A

of

ficer

and

all

agre

e ad

ditio

nal Q

ME

of d

iffer

ent

spec

ialty

nee

ded

QM

E M

inim

um A

vaila

bilit

y fo

r P

anel

s•

To h

elp

parti

es g

et Q

ME

app

oint

men

ts•

Pro

pose

d se

ctio

n §

32.7

•Q

ME

mus

t sch

edul

e, if

requ

este

d, o

n av

erag

e du

ring

a 90

-day

per

iod,

3x

the

appl

icab

le n

umbe

r of p

anel

app

oint

men

ts

per m

onth

per

cha

rt•

1 pa

nel c

ase

if do

es 1

-10

eval

uatio

ns/y

r•

2 pa

nel c

ases

if d

oes

11-2

4 ev

alua

tions

/yr

•3

pane

l cas

es if

doe

s ov

er 2

5/yr

Lim

it on

QM

E o

ffice

loca

tions

list

ed

with

DW

C•

Pro

pose

d §

§1

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QME Form 105 (rev. Aug. 2007) Page 1

State of California DIVISION OF WORKERS’ COMPENSATION - MEDICAL UNIT

REQUEST FOR QME PANEL UNDER LABOR CODE § 4062.1

UNREPRESENTED (Please Complete Form/Type or Print)

Request Date:______________________ The Party Making the Panel Request (Check one)

Unrepresented injured employee Employer/Claims Administrator

Please specify the reason for your request for a medical/legal examination by a QME. (See attachment on How to Request a Qualified Medical Evaluator for help in completing this section.) (Check one)

§ 4060 (causation exam) § 4061 (permanent disability dispute) § 4062 (medical treatment dispute) Check this box if your claim was denied altogether by the employer or insurer

EMPLOYEE INFORMATION Date of injury: Name: Address: City: State: Zip: Day time phone No.: (_____) If currently residing out of state, city and zip code at the time of injury: Representative (if any): Phone: (___) Address: City: State: Zip:

NOTE: If you are currently residing out of state, the panel will be issued using the California city and zip code where you were residing at the time of the injury. The claims administrator and injured worker may agree to another city and zip code instead of the city where you were residing in California. However, the DWC-Medical Unit needs a copy of your agreement with signatures from each (the injured employee and the employer/insurer). The city and zip code agreed upon must be in California.

EMPLOYER/INSURER or CLAIMS ADMINSTRATOR INFORMATION

Employer Name: W.C. Insurer/TPA: Claim No.: Address: City: State: Zip: Claims Adjuster (if known): Phone: (___) Attorney/Representative: Phone: (___) Address: City: State: Zip:

MEDICAL SPECIALITY REQUESTED

Please list ONLY ONE (insert three letter code from the list on the back of this page)

Specialty Requested: Signature of Requestor: Requestor name (print):

(Note: Any employer/claims administrator using this form to request a QME panel must attach a copy of correspondence sent to the injured employee furnishing the form and advising the employee how to request a QME.)

Send the completed form to: Division of Workers’ Compensation – Medical Unit

P.O. Box 71010, Oakland, CA 94612 (510) 286-3700 or (800) 794-6900

QME Form 105 (rev. Aug 2007) Page 2

For Use with the QME Panel Request Form 105

MD/DO SPECIALTY CODES NON-MD/DO SPECIALTY CODES

MAI Allergy and Immunology ACA Acupuncture MDE Dermatology DCH Chiropractic MEM Emergency Medicine DEN Dentistry MTT Emergency Medicine - Toxicology OPT Optometry MFP Family Practice POD Podiatry MPM General Preventive Medicine PSY Psychology MHH Hand – Orthopaedic Surgery PSN Psychology - Clinical Neuropsychology MMM Internal Medicine MMV Internal Medicine - Cardiovascular Disease MME Internal Medicine – Endocrinology Diabetes and

Metabolism MMG Internal Medicine - Gastroenterology MMH Internal Medicine - Hematology

MMI Internal Medicine - Infectious Disease MMN Internal Medicine - Nephrology MMP Internal Medicine - Pulmonary Disease MMR Internal Medicine - Rheumatology MNB Spine – Orthopaedic Surgery and Neurological

Surgery MPN Neurology MNS Neurological Surgery MOG Obstetrics and Gynecology MPO Occupational Medicine MMO Orthopaedic Surgery – Oncology, Internal

Medicine – Oncology, Radiology - Oncology MOP Ophthalmology MOS Orthopaedic Surgery MTO Otolaryngology MPA Pain Medicine MHA Pathology MEP Pediatrics MPR Physical Medicine & Rehabilitation MPS Plastic Surgery MPD Psychiatry MSY Surgery MHH Surgery - Hand MSG Surgery - General Vascular MTS Thoracic Surgery MUU Urology

STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS’ COMPENSATION MEDICAL UNIT MAILING ADDRESS: P.O. Box 71010 Oakland, CA 94612 (510) 286-3700 or (800) 794-6900

Over…

HOW TO REQUEST A QUALIFIED MEDICAL EVALUATOR IF YOU DO NOT HAVE AN ATTORNEY

(Attachment to Form 105) Since you do not have an attorney and there is a disagreement over some of the opinions of your treating physician, you need to complete QME Form 105 to obtain a panel of three Qualified Medical Evaluators (QMEs). The purpose of the QME examination is to obtain a second medical opinion to help resolve the disputed medical issues in your workers’ compensation claim(s). The QME report must discuss all of the disputed and unresolved issues in your claim that need a medical opinion. You, the injured worker, have the first opportunity to choose the type of physician to perform the exam. Complete this form to request a QME panel, write the medical specialty you prefer for the QME and return it to the DWC Medical Unit. Send a copy of your completed form to the employer/insurer as well. If you do not request a panel within ten (10) days of being asked to do so by the employer/insurer, then the employer/insurer has the right to request the panel and choose the medical specialty. The employer/insurer may not submit this form until ten (10) days have passed after the form was given to the injured worker with the instruction to send the completed form to the DWC Medical Unit. After you receive the panel list of three QME names, you must select a doctor and make an appointment. If you do not select a QME from the panel, schedule an appointment with the QME and inform the employer/insurer of your choice within 10 days of the date the Medical Unit issued the panel, you may lose the right to choose the QME and the exam date. You must tell the employer/insurer the time and date of your appointment. If the Medical Unit does not issue a panel within fifteen (15) working days of its receipt of a request for a QME panel in an unrepresented case, the employee may select any QME of his or her choice to do the evaluation. Selecting the reason for your request for a QME panel: Select § 4060 if your claim is “on delay” or if the insurance company disputes that your injury was caused by work (i.e. compensability) or denies your claim or if you disagree with the treating physician’s opinion that work was not a medical cause of your claimed injury or illness. If the employer/insurer has accepted any body part as compensable for this date of injury, this reason may not apply. The QME evaluation will be used to determine whether the employer is liable for this injury. Select § 4061 if permanent disability is in dispute. The dispute may be about the amount or percentage of permanent disability or whether there is any permanent disability. Either party may request the QME panel. Select § 4062 if medical treatment is in dispute. The dispute may be over whether any treatment is needed, whether further treatment is needed, the form or type of treatment or the frequency of treatment recommended by the treating physician. Either party may request the panel. Selecting the medical specialty: If necessary, request help from your treating physician in choosing the appropriate medical specialty for the QME. Use the list on the back of the panel request form to select a specialty. Enter the 3 letter code for the medical specialty you select on the front of the form.

Where will the QMEs be located?

Attachment to Form 105 (rev. Aug. 2007)

The DWC-Medical Unit uses a random selection program to name three QMEs to the panel. If there are too few QMEs of the specialty you request in your geographic area, then the system will pick QMEs from other geographic areas and the employer shall pay all reasonable and necessary travel expenses. What if I pick the wrong medical specialty and wish to change the medical specialty? You may request a change of medical specialty if you have not had the QME evaluation yet. When requesting the change in medical specialty, the injured worker and claims administrator must agree in writing to the change of medical specialty. Please refer to the QME panel number if you request another medical specialty. Insufficient information or incomplete form:

• If the panel request form is not fully completed then it will be returned to you.

• If we do not have sufficient QMEs in the medical specialty you chose, then the request will be returned to you asking that you pick a different medical specialty.

• If a QME panel was previously issued for this injured worker, then the new panel request will be returned by the Medical Unit with a request that you provide us with more information about the status of the claim for which the earlier QME panel was issued.

How long will it take to have the examination and to get the QME’s report? QMEs must be able to schedule and do your exam within 60 days of your call for an appointment. If a QME on the panel cannot, you are entitled to a replacement QME. You are entitled to the written QME report within 30 days of the date the QME starts the physical exam. At times, the QME may request the Medical Unit to extend the time for writing the report. The QME must notify you, the employer/insurer and the Medical Unit in order to get an extension approval. You will be notified of the Medical Unit’s decision. If the QME selected does not complete the evaluation report within 30 days of starting the examination or within the extension of time approved by the Medical Director, you have a choice. You may request that the Medical Unit replace the QME and start over, or instead you may agree in writing to wait until the QME report is completed, by using QME form 113 or 116. Even if you are willing to wait, if the employer or insurer chooses not to wait, a new QME or QME panel may be issued. In that case a QME or QME panel in the same specialty will be issued. What if there is a need for another QME report in a different specialty? Under very limited circumstances, there may be a need for an additional examination and report by a QME in a different specialty. Generally this will only occur if a Workers’ Compensation Judge orders the additional report, if the QME states in the report that an examination by a physician in another specialty is necessary or when the parties meet with an Information and Assistance Officer who determines the conditions for obtaining an additional report under section 31.5(b)(4) of Title 8 of the California Code of Regulations are met. Other questions? If you have any other questions about the QME process, please call the Division of Workers’ Compensation Medical Unit at 1-800-794-6900. If you have other general questions about your workers’ compensation claim, please call the Information and Assistance officer at the Division of Workers’ Compensation listed in your phone book, or look on our website at http://www.dir.ca.gov/dwc.

QME Form 106 (rev. May 2007) Page 1

State of California DIVISION OF WORKERS’ COMPENSATION MEDICAL UNIT

REQUEST FOR QME PANEL UNDER LABOR CODE §4062.2

REPRESENTED (Please Complete Form/Type or Print)

Request Date: The Party Making the Panel Request (Check one)

Applicant’s attorney (or injured employee) Defense attorney (or employer/claims adjuster)

Please specify the reason for your request for a medical/legal examination by a QME. (See instruction sheet attached regarding use of this form.) (Check one)

§ 4060 (causation exam) § 4061 (permanent disability dispute) § 4062 (medical treatment) Check here if claim was denied

EMPLOYEE INFORMATION

Date of injury: Name: Address: City: State: Zip: Day time phone No.: (_____) If currently residing out of state, city and zip code at the time of injury: Attorney/Representative: Phone: (___) Address: City: State: Zip:

EMPLOYER/INSURER or CLAIMS ADMINSTRATOR INFORMATION

Employer Name: W.C. Insurer/TPA: Claim No.: Address: City: State: Zip: Claims Adjuster (if known): Phone: (___) Attorney/Representative: Phone: (___) Address: City: State: Zip:

MEDICAL SPECIALITY REQUESTED

Please list ONLY ONE (insert three letter code from the list on the reverse side of form)

Specialty Requested: Signature of Requestor: Requestor name (print): Treating Physician Specialty: Specialty Preferred by other party (if known):

(NOTE: YOU MUST ATTACH A COPY OF YOUR WRITTEN PROPOSAL NAMING ONE OR MORE AMEs)

Send the completed form and copy of your written AME proposal to:

Division of Workers’ Compensation – Medical Unit P.O. Box 71010, Oakland, CA 94612

(510) 286-3700 or (800) 794-6900

QME Form 106 (rev. Aug 2007) Page 2

For Use with the QME Panel Request Form 106

MD/DO SPECIALTY CODES NON-MD/DO SPECIALTY CODES

MAI Allergy and Immunology ACA Acupuncture MDE Dermatology DCH Chiropractic MEM Emergency Medicine DEN Dentistry MTT Emergency Medicine - Toxicology OPT Optometry MFP Family Practice POD Podiatry MPM General Preventive Medicine PSY Psychology MHH Hand – Orthopaedic Surgery PSN Psychology - Clinical Neuropsychology MMM Internal Medicine MMV Internal Medicine - Cardiovascular Disease MME Internal Medicine – Endocrinology Diabetes and

Metabolism MMG Internal Medicine - Gastroenterology MMH Internal Medicine - Hematology

MMI Internal Medicine - Infectious Disease MMN Internal Medicine - Nephrology MMP Internal Medicine - Pulmonary Disease MMR Internal Medicine - Rheumatology MNB Spine – Orthopaedic Surgery and Neurological

Surgery MPN Neurology MNS Neurological Surgery MOG Obstetrics and Gynecology MPO Occupational Medicine MMO Orthopaedic Surgery – Oncology, Internal

Medicine – Oncology, Radiology - Oncology MOP Ophthalmology MOS Orthopaedic Surgery MTO Otolaryngology MPA Pain Medicine MHA Pathology MEP Pediatrics MPR Physical Medicine & Rehabilitation MPS Plastic Surgery MPD Psychiatry MSY Surgery MHH Surgery - Hand MSG Surgery - General Vascular MTS Thoracic Surgery MUU Urology

STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS

DIVISION OF WORKERS’ COMPENSATION – MEDICAL UNIT MAILING ADDRESS: P. O. Box 71010 Oakland, CA 94612 (510) 286-3700 or (800) 794-6900

Over…

HOW TO REQUEST A QUALIFIED MEDICAL EVALUATOR IN A REPRESENTED CASE

(Attachment to Form 106)

To request a panel of three QMEs for a represented case, please complete QME Form 106, attached to these instructions. When you have completed the form, return it to the Division of Workers’ Compensation-Medical Unit (DWC-MU) with a copy of your written proposal naming one or more physicians to be Agreed Medical Evaluators attached. You must send a copy of your completed form to the other party. If represented parties have been unable to agree on an Agreed Medical Evaluator within the time limits specified in the Labor Code, a medical evaluator must be selected from the names provided on the QME panel letter. The DWC-MU uses a random selection program to assign three QMEs to the panel. If there are too few QMEs of the specialty requested in the geographic area of the injured worker’s residence, the system will pick QMEs from other geographic areas and the employer is responsible for paying for necessary travel costs incurred. The non-requesting party will receive a copy of the panel letter when it is issued. If the Medical Unit does not issue a panel within thirty (30) working days of receiving the request for a QME panel, either party may seek an order from a Workers’ Compensation Administrative Law Judge that a QME panel be issued. Selecting the reason for your request for a QME panel: § 4060 applies if the claim is “on delay” or if the employer/insurer disputes that the injury is compensable. If the employer/insurer has accepted any body part as compensable for this date of injury, this reason may not apply. The claim form must have been filed with the employer. (Labor Code § 4060(c)). Either party in a represented case may request a QME panel to resolve the issue of compensability under § 4060. (Labor Code § 4062.2(b)). § 4061 applies if permanent disability is in dispute. The dispute may be about the amount or percentage of permanent disability or whether there is any permanent disability. Either party may request the QME panel. § 4062 applies if medical treatment is in dispute. The dispute may be over whether any treatment is needed, whether further treatment is needed, the form or type of treatment or the frequency of treatment recommended by the treating physician. Either party may request the panel. Selecting the medical specialty: Enter the 3 letter code from the reverse side of QME Form 106 for the medical specialty you select on the front of the form. If known, also state the medical specialty of the treating physician and the specialty preferred by the opposing party. Insufficient information or incomplete form:

• If the panel request form is not fully completed then it will be returned to you.

• If we do not have sufficient QMEs in the medical specialty you chose, then the request will be returned to you asking that you pick a different medical specialty.

Attachment to Form 106 (rev. Mar. 2007) 2

• If a QME panel was previously issued for this injured worker, the new panel request will be returned by the Medical Unit with a request that you provide us with more information about the status of the claim for which the earlier QME panel was issued.

The AME or QME selection process in represented cases: After the panel is issued, represented parties have ten (10) days to communicate and to agree on one QME from the list to serve as an Agreed Medical Evaluator. If the parties have not agreed on an AME by the 10th day after assignment of the panel, each party may then strike one name from the panel. The remaining QME shall serve as the medical evaluator. If a represented party fails to exercise the right to strike a name from the panel within three working days of gaining the right to do so, the other party may select any QME who remains on the panel to serve as the medical evaluator. (Labor Code §4062.2(c)). Scheduling the evaluation appointment: The represented employee is responsible for arranging the appointment for the examination. Upon his or her failure to inform the employer/insurer of the appointment within 10 days after the medical evaluator has been selected, the employer/insurer may arrange the appointment and notify the employee of the arrangements.

How long will it take to have the examination and to get the QME’s report? The QME must be able to schedule the exam within 60 days of the call for an appointment. If the QME cannot, you are entitled to a replacement. You also are entitled to an evaluation report within 30 days of the commencement of the exam by a panel-selected AME or QME. At times, an AME or QME may request the Medical Unit to extend the deadline for completing the report because the evaluator has not received test results or a consulting physician’s report or for legal ‘good cause’. The evaluator must notify the DWC-Medical Unit and you of the request for approval of an extension of time to complete the report. You will be notified of the Medical Unit’s decision. If the physician you choose cannot complete the report within 30 days or the extension of time approved by the Medical Director, you have a choice. The parties may both agree in writing (on QME form 113 or 116) to wait until the physician can complete the report, or either party may request a replacement panel of physicians. If this occurs, you must go through the selection process again. Obtaining a QME in a different specialty: Under the circumstances listed in section 31.5(b) of Title 8 of the California Code of Regulations, parties in a represented case may obtain an additional QME panel in a different specialty. All requests for an additional QME panel in a different specialty must be written with supporting information or documentation showing how one of the conditions in section 31.5(b) are being met. Other questions? If you have any questions about the QME process, please call the DWC-MU at 1-800-794-6900. Other questions about the workers’ compensation claim and dispute resolution process should be directed to an Information and Assistance officer at the Division of Workers’ Compensation office listed in your phone book, or look on our website at http://www.dir.ca.gov/dwc.