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Suzanne Honor-Vangerov James Fisher Division of Workers’ Compensation Medical Unit QME Panel Process LC 4060, 4061, 4062 Spinal Surgery Second Opinion.

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Presentation on theme: "Suzanne Honor-Vangerov James Fisher Division of Workers’ Compensation Medical Unit QME Panel Process LC 4060, 4061, 4062 Spinal Surgery Second Opinion."— Presentation transcript:

1 Suzanne Honor-Vangerov James Fisher Division of Workers’ Compensation Medical Unit QME Panel Process LC 4060, 4061, 4062 Spinal Surgery Second Opinion Process

2 QME Process Labor Code 4060 Pre April 19, 2004 Before Denial of Claim GAOE/COE Examination GConsultant or QME selected by Employer After Denial of Claim GQME Examination GSelected by Injured Worker/Applicant’s Attorney GAny QME in the state

3 QME Process LC 4060 Post April 19, 2004 Before Denial of Claim Represented GPanel QME. GPanel chosen per G not effective for dates of injury prior to January 1, Unrepresented GPanel QME. GEmployer requests IW get a panel. GPanel chosen per After Denial of Claim Unrepresented GPanel QME. GEmployer cannot request IW get a panel. GPanel chosen per Represented GPanel QME. GPanel chosen per G not effective for dates of injury prior to January 1, 2005.

4 QME Process LC 4061 Permanent Disability Disputes Unrepresented GNo time limit for dispute to be raised. GPanel chosen per Represented GNo time limit for dispute to be raised. GEmployer and Applicant’s attorney attempt to agree on an AME within days. GIf no agreement, panel chosen per GNot effective for dates of injury prior to January 1, 2005.

5 QME Process LC 4062 All Other Disputes Unrepresented GObject within 30 days from receipt of PTP report. GPanel chosen per Represented GObject within 20 days from receipt of PTP report. GEmployer and Applicant’s attorney attempt to agree on an AME within days. GIf no agreement, panel chosen per GNot effective for dates of injury prior to January 1, 2005.

6 QME Process LC Unrepresented Panels GMust use our form. Can be on letterhead, but no other changes to the form permitted. The form must be completely filled out. New forms are in the works. GThe employer needs to provide the form to the injured worker with any notices required by 4060, 4061 or GNotice needs to spell out the statutory deadlines. GThe injured worker has 10 days to submit the form to DWC Medical Unit.

7 LC Unrepresented Panels - cont. GIf injured worker doesn’t submit the form, the employer can submit it. GThe medical specialty is chosen by the requestor. GThe injured worker has 10 days from the panel issue date to select a QME and make an appointment. GIf the injured worker doesn’t select a QME and make an appointment within 10 days, the employer can make the selection.

8 QME Process LC Represented Panels GFor dates of injury on or after January 1, GParties must try to agree to an AME first. GEither party can request QME panel if no AME is chosen within days. GParty submitting the request for QME selects the medical specialty. GThe parties have 10 days after the QME panel is issued to choose an Agreed QME.

9 LC Represented Panels - cont. GIf the parties can’t agree on a QME from the panel, each one can strike one name from the list. GThe remaining QME will do the evaluation. GIf either party fails to exercise their right to strike a name within three working days, the other party can select a QME from doctors remaining on the panel. GThe employee must make the appointment and notify the employer within 10 days of the QME selection. If the employee doesn’t make the appointment within 10 days, the employer can make it.

10 When is a Panel Issued? GWhen a properly filled out request form is received. –Must have DOI, Claim Number, Specialty and Requestor’s Signature. –Claims adjusters must submit proof of notice to the injured worker. GWe have 15 working days from date of receipt to issue the panel. ONLY ON UNREPRESENTED CLAIMS. –If we miss our deadline, requestor can choose QME of his or her choice.

11 Number of Panels GNo panel will be issued if there is an existing open panel in our system unless: –None of the panel doctors is available. –If previous panel was already used for a different claim. –If claim was settled or resolved at the WCAB. –4060 claims. GThere is only one QME per case. (LC 4064) –If there is a need for more than one specialty, the QME can get a consultation from an appropriate specialist. (Section 32) –If a new issue arises after the injured worker has seen a QME, that QME remains on the case unless he or she becomes unavailable. A new panel will then be issued. (LC 4067)

12 Special Circumstances GInjured worker has sole right to get panel. –When the claim has already been denied. –When the claims adjuster hasn’t objected to either the PD or the treatment recommendations of the PTP.

13 Replacement Panels GSection 31.5 –QME doesn’t practice in specialty requested. –QME can’t schedule an appointment within 60 days. –Employee changed residence since panel was issued. –Doctor on panel is in same group practice as another doctor on the panel. –PTP is on the panel. –New panel based on employee’s work address (both parties must agree.) –Medical Director can replace for medical “good cause”. –Medical Director can change specialty if appropriate.

14 Replacement Panels, cont. GQME is unavailable per section 33. –Notifies Medical Unit of unavailability by submitting form. Change of address Medical or Family emergency –Can’t simply deny access to unrepresented injured workers. GViolation of section 34. –Must send appointment notification within 5 days. –Must make appointment at office address on panel. –Must notify if an interpreter needed.

15 Other Valid Replacement Reasons GDoctor on panel from same office as PTP. (Section 31) GLate Reports. (Section 38) –QME must issue report within 30 days of the exam (DOI after 1/1/94). –QME must submit supplemental reports within 60 days of request. –Extensions can be granted for good cause. GEx Parte Communication. (LC Section 40, 41) GQME Bias. (Section 41)

16 Invalid Reasons for Replacement GDoctors on panel are too far away. –We will change to work address with agreement of both parties. –If the selected specialty has too few doctors in the pool, we’ll change the specialty with the agreement of both parties. GInjured worker or adjuster doesn’t like anyone on the panel. GInjured worker changed his or her mind about the specialty.

17 Spinal Surgery Second Opinion LC 4062 (b) PTP requests Spinal Surgery authorization Employer must object within 10 days from receipt of PTP report. Unrepresented Injured Workers GDWC will assign SSSO doctor at random. GAppointment, if needed, set on expedited basis. GReport served within 45 days from receipt of initial authorization request.

18 Spinal Surgery Second Opinion Represented Injured Workers GParties have 10 days to agree on a SSSO doctor. GIf no agreement, DWC will assign at random. GAppointment, if needed, set on expedited basis. GReport served within 45 days from receipt of initial authorization request.

19 Spinal Surgery Second Opinion GSSSO Doctor recommends surgery –Employer must provide surgery GSSSO Doctor doesn’t recommend surgery –Employer must file DOR for a hearing

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21 For More Information GFor information on-line go to our web site –http://www.dir.ca.gov Click on Workers’ Compensation –Announcements –DWC/WCAB Forum –Forms and Guides –Frequently Asked Questions –DWC Newsline Archive


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