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QME Examination Test Questions FINAL
Treating physician reports and medical-legal evaluations are used to establish โ eligibility for benefits Unrepresented worker - if the employee does not inform the employer of the selection within ____ days of the assignment of a panel of qualified medical evaluators, then the employer may select the physician from the panel โ 10 SB-228 reforms of 2003 (Governor Davis) primarily addressed the following issues โ ACOEM Guidelines - 24 visit limit For a QME evaluation for compensability only (AOE/COE), DO NOT send the QME report to the following Part(ies)? โ Local DEU SB-899 reforms of 2004 (Governor Schwarzenegger) primarily addressed the following issues? โ AMA Impairment Guides and MPNs Which of the following is not a term used in California as ratable "word of art"? โ Often Who selects the QME โ Patient In 1913, the Boynton Act โ Required most employers to have workers' compensation coverage A trade-off between Employers and Employees is referred to as โ The Historic Compromise You are required to keep and maintain all the medical-legal BILLINGS for _____ years from the date of examination โ 3 years The employer provides workers' compensation BENEFITS โ regardless of fault A copy of the notice to request time extension to file a QME report must be sent to โ Medical Unit at DWC
The employer is required to pay benefits no matter who caused the injury, as long as the injury is โ AOE/COE If there is a serious and willful misconduct by the employEE the award may be โ decreased by 1/ If the employer is UNINSURED for workers' compensation the injured worker can โ Sue in Civil Court, Receive punitive damages for pain and suffering, have the District Attorney fine the Employer For dates of injuyr AFTER 01/01/2005, a QME must use โ American Medical Association Guide to the Evaluation of Permanent Impairment, 5th edition Unlawful discrimination for reporting a work injury is protected under โ L.C. 132a The chief method to apportion permanent disability is to use the โ subtraction method If the injured worker is not hospitalized and misses seven (7) days of work he/she is not paid TD for โ the first three (3) days "Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to imprisonment in the state prison for up to ____ years or a fine of up to $50,000 or both โ five (5) years Payments to compensate an employee who does not completely recover from an injury โ PD "Disability = Impairment + Loss earning capacity + Occupational title + Age" โ Formula for PD Means approximately 90-100 percent of the time, as a ratable "word of art" โ Constant For injuries on or after January 1, 1994 and before 01/01/2004 most workers will be limited to a _____ cap on Vocational Rehabilitation benefits under that plan โ $16, If there are no surviving dependents, the death benefit is paid to โ Department of Industrial Relations (DIR)
If there is no MPN, an employee may pre-designate a Chiropractor or Acupuncturist and may switch care to that Chiropractor or Acupuncturist _____ after notifying the employer โ Immediately An employer must report injuries to Cal/OSHA of any death or serious injury within
โ 24 hours Labor Code section 4600 refers to โ A Statute A local work comp Judge's decisions may be appealed by a part to โ WCAB Commissioners To hear the case as a whole โ en bank Who has the burden to prove that the injury or medical condition arises out of or in the course of an injured worker's employment โ Employee The DWC Medical Unit submits a QME panel list to the injured worker with ____ names (QME's) โ three (3) Who calls the QME, in an unrepresented case, to make the first appointment with the Patient โ Patient The appointment should be made within ___ days after the date the patient first contacts the QME's office โ Appointment must be scheduled within 25-60 days after the Patient first contacts the QME office If the QME appointment cannot be made within 60 days of a phone call โ the IW may accept a later appointment or as DEW Medical Unit for another name When an unrepresented IW makes an appointment, the QME must complete a notification form (QME Form 110) within ___ working days โ Five (5) With the DOI before 1994, the QME must submit the evaluation report within ___ days of the date of the exam โ 45 days
Ex Parte communication with an agreed Medical Evaluator or s QME selected from a panel .... โ Is PROHIBITED With DOI after 01/01/1994, the QME must submit the evaluation report within ___ days of the date of the exam โ 30 days The Employer/Insurer is also required to send medical records to unrepresented workers ___ days before this information is sent to the QME โ 30 days In an unrepresented case, if the IW does not have the Employee's Permanent Disability Questionnaire (DWC-AD Form 100) โ The QME office should provide the form to the IW In unrepresented case, the QME should receive a Request for Summary Rating Determination (DEU Form 101) from ____ โ Claims Administrator Unrepresented cases, which of the following does not receive a copy of the QME report โ DWC Medical Unit The DWC may grant an extension to file the evaluation report up to ___ days, if lab reports or consultative reports have not been received โ 30 days The request for extension of QME report must be mailed no later than ___ โ 5 days before the report is due IBR applies to any medical bill for which the date of service is on or after โ 01/01/ Providers who disagree with the outcome of the second review may request IBR within ___ days โ 30 days An application for IBR (DWC form IBR-1) can be completed and submitted electronically by registering as a user on the ___ IBR tracking system โ Maximus Federal A check or Money Order is pain by the Physician for the IBR fee in the amount of โ $195 ??
In the case of Jones v Target Stores, because the referral was for physical therapy, the referral was disallowed by the board because of the absence of preauthorization โ pre-authorization Self-referral and cross referral violations are prospected by โ District Attorney's Office Making a false or fraudulent workers' compensation claim is a felony subject to up to ____ years in prison or a fine of up to $______ or double the value of the fraud, whichever is greater, or by both imprisonment and fine โ five (5), $50, The legislative reforms of 2012 required the physician fee schedule to be based on the ___ fee schedule, which is maintained by the Centers for Medicare and Medicaid Services (CMS) โ RBRVS The conversion factor beginning in 2017 is calculated at ____% of Medicare (using the conversion factor in effect in July 2012 as the base year), updated for inflation โ 120% The RBRVS fee schedule has three basic elements โ RVUs, CF, GAF Work comp PTP reports are billed using โ California Specific Codes For paper billing forms for health care providers, the physician must use โ CMS 1500 forms Electronic bills are paid within ___ days of receipt of the bill and supporting documentation โ 15 days The provider is responsible for submitting a check or money order for the IBR fee and any required or supporting documentation as part of the paper application within ___ days after receipt of the second=review decision โ 30 days Regulations require the QME to serve the medical-legal report and Summary Findings Form 111 (if unrepresented) on the claims administrator, or if non the employer, and the injured worker within ____ days from the commencement of the examination โ 30 days Regulations require the QME to serve the medical-legal report and on the claims administrator and the injured worker within 30 days from the _____
โ Commencement of the examination If IW is unrepresented, the QME serves the QME report on the _____ โ DEU, Employee & Claims Administrator Factors of Disability include the following โ Subjective Factors Objective Factors Work Restrictions Loss Pre-Injury Capacity Impairment rating for DOI on or after 01/01/2005 is based on โ AMA Guides, 5th ed. The relationship between the conditions found on examination and the injury or occupational exposure is stated under ___ within the report โ Cause If there is permanent disability, and the injury is described as an aggravation to an existing condition, that issue should be addressed in the ____ section of the report โ Apportionment The report must contain the statement that the evaluator has not violated _______ that there has been NO ILLEGAL REFERRAL(S) โ L.C. 139. When the payment is not made for M-L Report, the "unreasonably unpaid" amount can be increased by ____% as a penalty โ 10% penalty Injuries that occurred on or after _____, may be evaluated by QMEs โ 01/01/ To qualify as a QME you must devote _____ in direct treatment of patients โ 1/ QMEs are appointed for ____ years term โ 2 years Once the employer provides the IW with the application (Form 105) to request a panel QME, the IW has how many days to request the panel โ 10 days Who notifies the parties that he/she has been selected to perform the Medical-Legal Evaluation โ Selected QME
โ 20 days Apportionment is included in which of the following reports โ PR- If the PTP finds that the employee is P&S with regard to all conditions and that the injury has resulted in permanent partial disability, he/she must also complete the ___ โ Physician's Return-To-Work & Voucher Report Medical-Legal reports, which are generated with the intent to resolve a dispute, are reimbursed according to the ___ โ Medical-Legal Fee Schedule With the exception of employees who have predesignated a physician, employers have MPN control medical treatment for ___ โ The life of the claim When can an IW change PTP with in the MPN โ After the 1st visit An employer with an MPN which of the following CANNOT be pre-designated โ D.C. Which of the following is okay for a physician to refer a person โ PT services provided in your own clinic A violation of L.C. 139(a) conflict of interest referral is a misdemeanor subject to civil penalties up to $____ per offense โ $5, If you agree to refer patients to another clinic and they agree to refer to you โ This is subject to $15,000 per violation and subject to revocation of professional license When workers are unable to perform any work, they receive ___ benefits โ Temporary Total Disability (TTD) If full wages are paid, an IW may still receive TD benefits โ FALSE The employer has ___ days from the notification of the injury to contest the claim โ 90 days From January 1, 2008, to the present, TD may last up to ___ weeks within five years from the DOI โ 104
Supplement Job Displacement Benefits (SJDB) vouchers apply to workers injured on or after January 1, ____ โ 2004 SJDBs (Supplement Job Displacement Benefits) after 01/01/2013 are limited to ____ โ $6, Death benefits are payments to a spouse, the children, or other dependents, including reasonable burial expenses, not exceeding $____ for injuries before 01/01/2013 and $_____ for injuries on or after 01/01/ โ Before 01/01/2013 $5, After 01/01/2013 $10, For DOI after 01/01/1990 or DOI after 01/01/2003, DISABLED MINORS receive benefits โ For life Maximum Death Benefit (3 or more dependents) is ___ โ $320, Which of the following reports are not completed by the PTP โ QME or AME The claims administrator will pay the medical costs of approved medical services so the injured workers should ___ โ Never see a bill If the claims administrator denies treatment recommended by the PTP, the IW may request ___ using the request form included with the claims administrator's written decision to deny treatment โ IMR If there is a non-MPN, an employee can pre-designate โ M.D. D.O. D.C. Acupuncturist If the DOI is January 1, 2004, or later, a Chiropractor cannot be the treating physician after the first 24 Chiropractic visits unless the Employer has authorized additional visits in writing True/False โ True Presumptions for fire fighters, forestry officers, peace officers, and correctional employees cover conditions that manifest or develop during the prior of active service and following termination of service for up to ____ years
Utilization Review (UR) is the process used by employers or claims administrators to determine whether a requested treatment or other service is โ Medically Necessary Requests for treatment are submitted on the ____ form โ RFA Disputes over medical treatment for all dates of injury are now resolved by physicians through ____ โ IMR The costs of IMR are paid by _____ โ The Employers If UR denies, delays or modifies a treating physician's request for medical treatment because the treatment is not medically necessary, the ____ can ask for a review of that decision through IMR โ Injured Employee The IMR decision must be provided in writing to all parties in layperson's terms within _____ for an EXPEDITED request โ 72 hours The law specifies an Order of Medical Evidence Standards (place in order highest standard to lowest standard) โ (1) The guidelines, including the drug formulary, adopted by the administrative director pursuant to Section 5307.27 (MTUS) (2) Peer-Reviewed Scientific and Medical Evidence regarding the effectiveness of the disputed service (3) Nationally recognized professional standards (4) Expert Opinion (5) Generally accepted standards of medical practice (6) Treatments that are likely to provide a benefit to a patient for conditions for which other treatments are not clinically efficacious
