QME QUESTIONS WITH COMPLETE
SOLUTIONS
QME - correct answer--Qualified Medical Examiner
permanent and stationary - correct answer--When a condition reaches a state of
maximal medical improvement.
Escobedo case - correct answer---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
Rolda issues/Limits on compensability of psych issues - correct answer--1. Did psych
injury involve "actual events of employment"? (IW has burden of proof)
2. Is there >50% industrial causation (IW burden)
3. Was there personnel action and was it lawful, non-discriminatory, and in good faith?
(Defense burden)
4. Were personnel actions the substantial (>35-40%) cause of the psych injury.
(defense burden)
Granado case - correct answer---Set standard that medical tx (MT) is not apportionable
Benson case - correct answer---Clarified parsing out impairment to different injury dates
-If they can't be parceled out, you can say they are "inextricably intertwined."
Guzman case/Almaraz-Guzman standard - correct answer---Alternative rating of
disability (when case is complex/extraordinary and AMA good doesn't accurately reflect
the persons impairment)
-WPI rating can be made if it's accurate and based on AMA guides (fairness is not
allowed anymore)
Blackledge v BofA - correct answer--WCAB defined roles for:
-physician
-DEU rater
-parties
-Work comp judge
Blackledge case: physician requirements - correct answer--1. Compare medical findings
2. List WPI for each med condition
3. Select impairment in the range based on impact on 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
Alternative rating under Almaraz/Guzman - correct answer--1. Begin w strict rating
found in the chapter address the injured body part
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
Original intent of WC - correct answer---Provide minimum level of benefits promptly
-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
Boyton act - correct answer---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
Historic compromise - correct answer---Trade-off of rights and benefits
-Employee gives up right to sue for lots of $ and gets protection from legal system
against discrimination
-Employer provides benefits regardless of fault in exchange for protection from lawsuits
-3 components
1. No fault
2. Exclusive remedy
3. Assured and fixed benefits
No Fault & exceptions - correct answer---Employer pays benefits no matter who caused
injury, as long as it occurred during employment
*Exceptions
-self inflicted injury
-injury from serious/willful misconduct by employee: benefits 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
Exclusive Remedy - correct answer--Workers' compensation benefits are the only
benefits injured workers may receive to compensate for a work-related injury. (Even if
employer negligent)
-unless employer uninsured
-or third party is involved, that party can be sued
, Assured & Fixed Benefits - correct answer---WC has defined benefits employer must
pay
-WC is a statutory benefit w no arbitrary limits on freq, duration, or extent of services
Benefits provided by WC system - correct answer---Medical
-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 recover
-Vocational: no longer; now provides Supp Job Displacement Benefits (SJDB)
-Death: 1 dep: $125,000, 2 dep: 135,000, 3+ dep: 160,000
Claims adjudication Unit - correct answer--WC judges and staff; first level in determining
claim
Disability eval Unit - correct answer--Disability evaluator/raters that determine PD
ratings
Info and Assistance Unit - correct answer---Assists on rights, benefits, and obligations
under CA WC laws
-Officer helps resolve misunderstandings, disputes, and complaints from claims for
compensation
Rehab Unit - correct answer--Makes determinations of disputes in vocational rehab
Audit and Enforcement Unit - correct answer--Conducts audits on insurance co., self
insured employer, and 3rd party admin.; ensures benefits are paid accurately and timely
Uninsured employer fund/Collections unit - correct answer--Pays benefits to IW w/
illegally uninsured employer & pursues recovery
Medical Unit - correct answer---Executive med director; performs services related to
delivery 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
DEU ratings - correct answer--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 admin or IW
Workers Comp Info System (WCIS) - correct answer---Uses electronic record keeping
data to collect info from claims admin to help DIR oversee WC system
-All elements/documents of claim (reports, notices, med billing) are required to be
electronic as of 9/22/06
SOLUTIONS
QME - correct answer--Qualified Medical Examiner
permanent and stationary - correct answer--When a condition reaches a state of
maximal medical improvement.
Escobedo case - correct answer---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
Rolda issues/Limits on compensability of psych issues - correct answer--1. Did psych
injury involve "actual events of employment"? (IW has burden of proof)
2. Is there >50% industrial causation (IW burden)
3. Was there personnel action and was it lawful, non-discriminatory, and in good faith?
(Defense burden)
4. Were personnel actions the substantial (>35-40%) cause of the psych injury.
(defense burden)
Granado case - correct answer---Set standard that medical tx (MT) is not apportionable
Benson case - correct answer---Clarified parsing out impairment to different injury dates
-If they can't be parceled out, you can say they are "inextricably intertwined."
Guzman case/Almaraz-Guzman standard - correct answer---Alternative rating of
disability (when case is complex/extraordinary and AMA good doesn't accurately reflect
the persons impairment)
-WPI rating can be made if it's accurate and based on AMA guides (fairness is not
allowed anymore)
Blackledge v BofA - correct answer--WCAB defined roles for:
-physician
-DEU rater
-parties
-Work comp judge
Blackledge case: physician requirements - correct answer--1. Compare medical findings
2. List WPI for each med condition
3. Select impairment in the range based on impact on 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
Alternative rating under Almaraz/Guzman - correct answer--1. Begin w strict rating
found in the chapter address the injured body part
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
Original intent of WC - correct answer---Provide minimum level of benefits promptly
-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
Boyton act - correct answer---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
Historic compromise - correct answer---Trade-off of rights and benefits
-Employee gives up right to sue for lots of $ and gets protection from legal system
against discrimination
-Employer provides benefits regardless of fault in exchange for protection from lawsuits
-3 components
1. No fault
2. Exclusive remedy
3. Assured and fixed benefits
No Fault & exceptions - correct answer---Employer pays benefits no matter who caused
injury, as long as it occurred during employment
*Exceptions
-self inflicted injury
-injury from serious/willful misconduct by employee: benefits 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
Exclusive Remedy - correct answer--Workers' compensation benefits are the only
benefits injured workers may receive to compensate for a work-related injury. (Even if
employer negligent)
-unless employer uninsured
-or third party is involved, that party can be sued
, Assured & Fixed Benefits - correct answer---WC has defined benefits employer must
pay
-WC is a statutory benefit w no arbitrary limits on freq, duration, or extent of services
Benefits provided by WC system - correct answer---Medical
-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 recover
-Vocational: no longer; now provides Supp Job Displacement Benefits (SJDB)
-Death: 1 dep: $125,000, 2 dep: 135,000, 3+ dep: 160,000
Claims adjudication Unit - correct answer--WC judges and staff; first level in determining
claim
Disability eval Unit - correct answer--Disability evaluator/raters that determine PD
ratings
Info and Assistance Unit - correct answer---Assists on rights, benefits, and obligations
under CA WC laws
-Officer helps resolve misunderstandings, disputes, and complaints from claims for
compensation
Rehab Unit - correct answer--Makes determinations of disputes in vocational rehab
Audit and Enforcement Unit - correct answer--Conducts audits on insurance co., self
insured employer, and 3rd party admin.; ensures benefits are paid accurately and timely
Uninsured employer fund/Collections unit - correct answer--Pays benefits to IW w/
illegally uninsured employer & pursues recovery
Medical Unit - correct answer---Executive med director; performs services related to
delivery 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
DEU ratings - correct answer--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 admin or IW
Workers Comp Info System (WCIS) - correct answer---Uses electronic record keeping
data to collect info from claims admin to help DIR oversee WC system
-All elements/documents of claim (reports, notices, med billing) are required to be
electronic as of 9/22/06
