Post on 25-Mar-2018
transcript
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PRESENTEDBY
MelissaHicksDWCMEDICALUNITMANAGERJimFisherandKarenPakDWCCOUNSEL
THEQMEPROCESSREVEALED:GettingyourQMEpanelrequestfilled
bytheMedicalUnit
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QMEPanelProductionUpdate
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QMEpanelsreceivedannually
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2012 2013
Thousands
Unrepresented
Represented
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Improvements
Clearcommunication
Priorityresubmissions
Eliminatingbacklog
Electronicsolution
ResourcesontheDWCwebsite
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Whattothinkaboutbeforeyoufile?
DoIhaveadisputethatcanberesolvedbyaQME?
Some“disputes”cannotberesolvedbyaQMEevaluation.
Currentmedicaltreatmentdisputes.(Lab.Code 4062(c).)
WhethermedicaltreatmentshouldbeprovidedintheMedicalProviderNetwork.(Knight)
Thereasonablenessofpastmedicaltreatment?(Lab.Code?4062.)
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Whatisthesubstantiveissuethatneedsresolution?
IsthisanAOE/COEdispute?
Didtheprimarytreatingphysicianfindtheinjuredworker
P&SorMMI?
IftheinjuredworkerisnotP&SorMMI,whatfindingofthe
primarytreatingphysicianamIdisputing?
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BasisforrequestingQMEpanels:LaborCode 4060,4061,4062
LaborCode 4060:Disputesovercompensabilityofaclaimedinjury
LaborCode 4061:Disputesoverpermanentdisabilityandtheneedforfuturemedicalcare
LaborCode 4062:DisputesovermedicalissuesnotcoveredbyLaborCode 4060or4061andnotsubjecttoLaborCode 4610
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HowDoIGeta4060PanelFilled?
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GettingyourQMEpanelrequestfilledbytheMedicalUnit
LaborCode 4060
Thissectionshallapplytodisputesoverthecompensabilityofanyinjury.Thissectionshallnotapplywhereinjurytoanypartorpartsofthebodyisacceptedascompensablebytheemployer.
Ifamedicalevaluationisrequiredtodeterminecompensabilityatanytimeafterthefilingoftheclaimform
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LaborCodesection4060disputes
UnrepresentedCases
“theemployershallprovidetheemployeewithnoticeeitherthattheemployerrequestsacomprehensivemedicalevaluationtodeterminecompensabilityorthattheemployerhasnotacceptedliabilityandtheemployeemayrequestacomprehensivemedicalevaluationtodeterminecompensability.Eitherpartymayrequestacomprehensivemedicalevaluationtodeterminecompensability.TheevaluationshallbeobtainedonlybytheprocedureprovidedinSection4062.1.”(LaborCodesection4060(d).)
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GettingyourQMEpanelrequestfilledbytheMedicalUnit
Representedcases‐LaborCode 4060
Ifamedicalevaluationisrequiredtodeterminecompensabilityatanytimeafterthefilingoftheclaimform,andtheemployeeisrepresentedbyanattorney,amedicalevaluationtodeterminecompensabilityshallbeobtainedonlybytheprocedureprovidedinSection4062.2.
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LaborCodesection4060‐Unrepresented
Completetheform105
Rule30requiresthepartiesto“attacharequestaforanexaminationtodeterminethecompensabilityunderLaborCodesection4060.”(Cal.CodeofRegs.tit.8, 30(a)(1).)
Deniallettersmaybeattachedtotherequest.
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LaborCodesection4060‐represented
Completetheform106accurately,includingtheproofofservice.Makesureyou:
1) DesignateaspecialtyfortheQMEpanelrequested
2) Statethespecialtypreferredbytheopposingparty,ifknownand;
3) Statethespecialtyofthetreatingphysician
Attachthe“requestletter”(Cal.CodeofRegs.tit.8,30(b)(1).)
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HowdoIgeta4061or4062panelfilled?
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GettingyourQMEpanelrequestfilled
BothLaborCodesection4061and4062requiretherebeanobjectiontomedicaldeterminationmadebyaprimarytreatingphysician.
LaborCodesection4061wasamendedin2012torequiretorequireanobjection.(Appliestorepresentedandunrepresentedcases.)
LaborCodesection4062hasrequiredanobjectionsince1993.
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MedicalDetermination
CalCodeofRegs,tit.,8, 9785
“Medicaldetermination”means,forthepurposeofthis
section,adecisionmadebytheprimarytreatingphysician
regardinganyandallmedicalissuesnecessarytodetermine
theemployee'seligibilityforcompensation.(CalCodeofRegs,
tit.,8, 9785(a)(4).)
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PrimaryTreatingPhysician
CalCodeofRegs,tit.,8, 9785
The“primarytreatingphysician”isthephysicianwhoisprimarilyresponsibleformanagingthecareofanemployee,andwhohasexaminedtheemployeeatleastonceforthepurposeofrenderingorprescribingtreatmentandhasmonitoredtheeffectofthetreatmentthereafter.(CalCodeofRegs,tit.,8, 9785(a)(1).)
A“secondaryphysician”isanyphysicianotherthantheprimarytreatingphysicianwhoexaminesorprovidestreatmenttotheemployee,butisnotprimarilyresponsibleforcontinuingmanagementofthecareoftheemployee.(CalCodeofRegs,tit.,8, 9785(a)(2).)
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GettingyourQMEpanelrequestfilled
Iftheemployeedisputesamedicaldeterminationmadebytheprimarytreatingphysician,includingadeterminationthattheemployeeshouldbereleasedfromcare,thedisputeshallberesolvedundertheapplicableproceduressetforthatLaborCodesections4061and4062.(CalCodeofRegs,tit.,8, 9785(b)(3).)
Iftheclaimsadministratordisputesamedicaldeterminationmadebytheprimarytreatingphysician,thedisputeshallberesolvedundertheapplicableproceduressetforthatLaborCodesections4610,4061and4062.(CalCodeofRegs,tit.,8, 9785(b)(4).)
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LaborCodesection4061Disputes
UnrepresentedCases
Ifeithertheemployeeoremployerobjectstoamedicaldeterminationmadebythetreatingphysicianconcerningtheexistenceorextentofpermanentimpairmentandlimitationsortheneedforfuturemedicalcare,andiftheemployeeisnotrepresentedbyanattorney,theemployershallimmediatelyprovidetheemployeewithaformprescribedbythemedicaldirectorwithwhichtorequestassignmentofapanelofthreequalifiedmedicalevaluators.(Lab.Code 4061(c).)
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LaborCodesection4061disputes
Representedcases
Ifeithertheemployeeoremployerobjectstoamedicaldeterminationmadebythetreatingphysicianconcerningtheexistenceorextentofpermanentimpairmentandlimitationsortheneedforfuturemedicalcare,andtheemployeeisrepresentedbyanattorney,amedicalevaluationtodeterminepermanentdisabilityshallbeobtainedasprovidedinSection4062.2.(Lab.Code 4061(b).)
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GettingyourQMEpanelrequestfilled
IfthereisnotamedicalreportfromthePTPthatcontainsadeterminationconcerningtheexistenceofpermanentdisabilityand/orwhethertheinjuredworkerneedsfuturemedicalcarethenyoudon’thaveadisputeaboutPDunderLaborCodesection4061.
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LaborCodesection4062disputes
IfeithertheemployeeoremployerobjectstoamedicaldeterminationmadebythetreatingphysicianconcerninganymedicalissuesnotcoveredbySection4060or4061andnotsubjecttoSection4610,theobjectingpartyshallnotifytheotherpartyinwritingoftheobjectionwithin20daysofreceiptofthereportif theemployeeisrepresentedbyanattorneyorwithin 30daysofreceiptofthereportiftheemployeeisnotrepresentedbyanattorney.Thesetimelimitsmaybeextendedforgoodcauseorbymutualagreement.(Lab.Code 4062(a).)
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LaborCodesection4062.1
Unrepresentedcases
Filetheform105
attachawrittenobjectionindicatingtheidentityoftheprimarytreatingphysician,thedateoftheprimarytreatingphysician'sreportthatisthesubjectoftheobjectionandadescriptionofthemedicaldeterminationthatrequiresacomprehensivemedical‐legalreporttoresolve,…;and
designateaspecialtyfortheQMEpanelrequested.(Cal.CodeofRegs. 30(a).)
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LaborCodesection4062.1
Theemployermaynotsubmittheformunlesstheemployeehasnotsubmittedtheformwithin10daysaftertheemployerhasfurnishedtheformtotheemployeeandrequestedtheemployeetosubmittheform.Thepartysubmittingtherequestformshalldesignatethespecialtyofthephysiciansthatwillbeassignedtothepanel.
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LaborCodesection4062.2
Completetheform106accurately,includingtheproofofService.Makesureyou:
designateaspecialtyfortheQMEpanelrequested
statethespecialtypreferredbytheopposingparty,ifknownand
statethespecialtyofthetreatingphysician.
Attachtheawrittenobjectionletterindicatingtheidentityoftheprimarytreatingphysician,thedateofthereport,andadescriptionofthemedicaldispute.(Cal.CodeofRegs.,tit.8,section30(b).)
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Timelinessofrequest
WhencantheRepresentedQMEPanelRequestbesubmittedtotheMedicalUnit?
Partiesmustwait10daysafterwrittenobjectiontoamedicaldisputepursuanttooneofthesections(LaborCode 4061and4062)
Anadditional5daysformailingisrequired(Messelev.PitcoFoods,Inc.(76CCC956))
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QUESTIONS?
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Tipstoshortenwaittime
RESUBMISSIONS
AttachrejectionletterascoverpagewhenresubmittingcorrectedQMEpanelrequest– includecopyoforiginalformtostreamline
Additionalresources:QMEformsinDWCwebsiteat:http://www.dir.ca.gov/dwc/forms.html#QMEForms
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REPLACEMENTPANELS
Replacementpanels– section31.5oftitle8
Formisnowmandatory
Objecttopreserveyourrights
ExecutiveMedicalDirectorhasdiscretiontoreplaceallorpartofthepanel
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AdditionalPanelRequests
Additionalpanelrequests– section31.7oftitle8
Changedintheemergencyregulationphase.
Pushesthepartiestodiscusstheneedfortheadditionalpanelandthespecialtyrequired.
EliminatedtheabilityofaQMEtorequestaconsulttocompletetheirevaluation.
Ifthepartiescannotagreeaboutneedorspecialtytoresolvethedispute,takeittotheappealsboard.
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HELPFULTIPS
Besimple
Beclear
Bedirect
“Theapplicant,FoghornLeghorn©,requestsaQMEtodeterminethecompensabilityofthisclaim.”
“AcmeInsurancecompanyobjectstothefindingofnopermanentdisabilitymadebythePTP,WileE.Coyote©,inhisreportofAugust3,2013.”
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HELPFULTIPS
Accuracyonthepanelisimportant.
KnowthedifferencebetweenLaborCodesection4061(PD)andLaborCodesection4062(natureandextentcases)
IftheissueofthecompensabilityofabodypartarisesinUR,saythatintheobjectionlettertotheopposingcounsel.
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