QME EXAM NEWEST 2024 ACTUAL EXAM COMPLETE 220 QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
Study online at https://quizlet.com/_fuqq64
1. QME Qualified Medical Examiner
2. permanent and When a condition reaches a state of maximal medical
stationary improvement.
3. Escobedo case -Set standard of reasonable medical probability (standard
a physician is expected to follow, that based on superior
evidence, something is probably/more likely than not)
-These words turn the report into substantial evidence
4. Rolda 1. Did psych injury involve "actual events of employment"?
issues/Limits on (IW has burden of proof)
compensability 2. Is there >50% industrial causation (IW burden)
of psych issues 3. Was there personnel action and was it lawful, non-dis-
criminatory, and in good faith? (Defense burden)
4. Were personnel actions the substantial (>35-40%)
cause of the psych injury. (defense burden)
5. Granado case -Set standard that medical tx (MT) is not apportionable
6. Benson case -Clarified parsing out impairment to different injury dates
-If they can't be parceled out, you can say they are "inex-
tricably intertwined."
7. Guzman -Alternative rating of disability (when case is complex/ex-
case/Al- traordinary and AMA good doesn't accurately reflect the
maraz-Guzman persons impairment)
standard -WPI rating can be made if it's accurate and based on
AMA guides (fairness is not allowed anymore)
8. Blackledge v WCAB defined roles for:
BofA -physician
-DEU rater
-parties
-Work comp judge
9. Blackledge case: 1. Compare medical findings
physician re- 2. List WPI for each med condition
quirements 3. Select impairment in the range based on impact on
, QME EXAM NEWEST 2024 ACTUAL EXAM COMPLETE 220 QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
Study online at https://quizlet.com/_fuqq64
ADLs
4. ADL analogies
-Role of evaluator is to assess WPI % by a report that sets
forth facts and reasoning to support conclusions and are
in line with AMA & case law
10. Alternative rat- 1. Begin w strict rating found in the chapter address the
ing under Al- injured body part
maraz/Guzman 2. Explain what specific facts require an alternative rating
3. Provide analysis as to why alternative rating is more
accurate
4. Set forth how Dr arrived at alt rating
5. State position with reasonable medical probability
11. Original intent of -Provide minimum level of benefits promptly
WC -To prevent IW from becoming a burden on others and
help IW return to work thru rehab
-Help dependents if IW dies
-MT for job related injuries/illness
-TD benefits for lost wages
-PD benefits for finished ability to compete in open labor
market
12. Boyton act -1913: required most employers to have WC coverage
-Later expanded to include provision that when rating
disability, persons diminished ability to compete in open
job market should be considered
13. Historic compro- -Trade-off of rights and benefits
mise -Employee gives up right to sue for lots of $ and gets
protection from legal system against discrimination
-Employer provides benefits regardless of fault in ex-
change for protection from lawsuits
-3 components
1. No fault
2. Exclusive remedy
3. Assured and fixed benefits
14.
, QME EXAM NEWEST 2024 ACTUAL EXAM COMPLETE 220 QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
Study online at https://quizlet.com/_fuqq64
No Fault & ex- -Employer pays benefits no matter who caused injury, as
ceptions long as it occurred during employment
*Exceptions
-self inflicted injury
-injury from serious/willful misconduct by employee: ben-
efits reduced by half unless employee died or has PD of
70% or more
-injury from failure of employer to comply with health and
safety reg
-employee was under 16yo
15. Exclusive Reme- Workers' compensation benefits are the only benefits
dy injured workers may receive to compensate for a work-re-
lated injury. (Even if employer negligent)
-unless employer uninsured
-or third party is involved, that party can be sued
16. Assured & Fixed -WC has defined benefits employer must pay
Benefits -WC is a statutory benefit w no arbitrary limits on freq,
duration, or extent of services
17. Benefits provid- -Medical
ed by WC system -TD payments: paid while injury is being tx, before it is PD
-PD payments: determined by loss of ADLs that contribute
to WPI; compensates employee who does not fully recov-
er
-Vocational: no longer; now provides Supp Job Displace-
ment Benefits (SJDB)
-Death: 1 dep: $125,000, 2 dep: 135,000, 3+ dep: 160,000
18. Claims adjudica- WC judges and staff; first level in determining claim
tion Unit
19. Disability eval Disability evaluator/raters that determine PD ratings
Unit
20. Info and Assis- -Assists on rights, benefits, and obligations under CA WC
tance Unit laws
, QME EXAM NEWEST 2024 ACTUAL EXAM COMPLETE 220 QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)
Study online at https://quizlet.com/_fuqq64
-Officer helps resolve misunderstandings, disputes, and
complaints from claims for compensation
21. Rehab Unit Makes determinations of disputes in vocational rehab
22. Audit and En- Conducts audits on insurance co., self insured employer,
forcement Unit and 3rd party admin.; ensures benefits are paid accurate-
ly and timely
23. Uninsured em- Pays benefits to IW w/ illegally uninsured employer &
ployer fund/Col- pursues recovery
lections unit
24. Medical Unit -Executive med director; performs services related to de-
livery of med benefits
-Est. policy and guidelines for tx and eval of IW
-Appoints QMEs; investigates complaints on QMEs
-Approves/certifies and oversees MPNs and HCO
-Helps set med fee schedule
25. DEU ratings 1. Formal: done at request of WC judge
2. Consultative: done on litigated cases at request of
attorney or DW info assist officer
3. Summary: non-litigated cases at request of claims ad-
min or IW
26. Workers Comp -Uses electronic record keeping data to collect info from
Info System claims admin to help DIR oversee WC system
(WCIS) -All elements/documents of claim (reports, notices, med
billing) are required to be electronic as of 9/22/06
27. Subsequent in- -Source of add. compensation for IW who already had
jury bene- disability at time of injury
fits trust fund -Need combined effect of at least 70%
(SIBTF) -Employer can hire disabled workers w/o fear of liability
for effects of prev. disability
28. WCAB Workers Comp Appeals Board; 7 commissioners, 5 of
which are attorneys
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