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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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